Provider Demographics
NPI:1700035458
Name:ROTH, AMY N (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:N
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 145
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3263
Mailing Address - Country:US
Mailing Address - Phone:847-685-9900
Mailing Address - Fax:847-685-6390
Practice Address - Street 1:444 N NORTHWEST HWY
Practice Address - Street 2:SUITE 145
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3263
Practice Address - Country:US
Practice Address - Phone:847-685-9900
Practice Address - Fax:847-685-6390
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0111841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical