Provider Demographics
NPI:1619746930
Name:ROTH, MARISA JEANE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JEANE
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 1:129 COEN MOBILE HOME LN
Mailing Address - Street 2:
Mailing Address - City:RUFFS DALE
Mailing Address - State:PA
Mailing Address - Zip Code:15679-1738
Mailing Address - Country:US
Mailing Address - Phone:724-771-0067
Mailing Address - Fax:
Practice Address - Street 1:1501 LIGONIER ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-2912
Practice Address - Country:US
Practice Address - Phone:724-804-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1310451041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool