Provider Demographics
NPI:1770636771
Name:ROTH-LAUBE, LYDIA GAIL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:GAIL
Last Name:ROTH-LAUBE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 CEDARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3823
Mailing Address - Country:US
Mailing Address - Phone:952-927-4746
Mailing Address - Fax:
Practice Address - Street 1:1660 HIGHWAY 100 S STE 142
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1562
Practice Address - Country:US
Practice Address - Phone:952-544-5719
Practice Address - Fax:952-544-5719
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2153103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical