Provider Demographics
NPI:1710139258
Name:ROTH, MAYA (ND)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 N POINSETTIA PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-2505
Mailing Address - Country:US
Mailing Address - Phone:323-333-3400
Mailing Address - Fax:
Practice Address - Street 1:322 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2518
Practice Address - Country:US
Practice Address - Phone:323-395-9777
Practice Address - Fax:323-395-5171
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-329175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath