Provider Demographics
NPI:1619565645
Name:ROTH, MARIA JEANETTE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JEANETTE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3826 73RD AVENUE CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-6415
Mailing Address - Country:US
Mailing Address - Phone:253-331-9168
Mailing Address - Fax:
Practice Address - Street 1:3826 73RD AVENUE CT NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-6415
Practice Address - Country:US
Practice Address - Phone:253-331-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst