Provider Demographics
NPI:1689354573
Name:DR. MARK ROTH AND ASSOCIATES
Entity Type:Organization
Organization Name:DR. MARK ROTH AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-459-6755
Mailing Address - Street 1:2984 CAMEO DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9313
Mailing Address - Country:US
Mailing Address - Phone:317-459-6755
Mailing Address - Fax:317-296-7207
Practice Address - Street 1:333 N ALABAMA ST STE 350
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-2275
Practice Address - Country:US
Practice Address - Phone:317-459-6755
Practice Address - Fax:317-296-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty