Provider Demographics
NPI:1669682563
Name:ROTH, EDWARD A III (NMT, MT-BC)
Entity Type:Individual
Prefix:PROF
First Name:EDWARD
Middle Name:A
Last Name:ROTH
Suffix:III
Gender:M
Credentials:NMT, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 IROQUOIS TRL
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2032
Mailing Address - Country:US
Mailing Address - Phone:269-373-0426
Mailing Address - Fax:
Practice Address - Street 1:3415 IROQUOIS TRL
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2032
Practice Address - Country:US
Practice Address - Phone:269-373-0426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist