Provider Demographics
NPI:1760235386
Name:ROTH, KRISTY LEIGH (CASAC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEIGH
Last Name:ROTH
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1603
Mailing Address - Country:US
Mailing Address - Phone:607-296-3072
Mailing Address - Fax:607-296-3079
Practice Address - Street 1:249 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1603
Practice Address - Country:US
Practice Address - Phone:607-296-3072
Practice Address - Fax:607-296-3079
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35424101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)