Provider Demographics
NPI:1679672570
Name:ROTH, JOANNE THERESE (LMSW)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:THERESE
Last Name:ROTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2769
Mailing Address - Country:US
Mailing Address - Phone:313-886-3811
Mailing Address - Fax:
Practice Address - Street 1:22708 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1823
Practice Address - Country:US
Practice Address - Phone:586-445-2210
Practice Address - Fax:580-445-0700
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801011882104100000X, 1041C0700X
MI4101005871106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ26426266Medicare ID - Type Unspecified