Provider Demographics
NPI:1780823245
Name:ROTH, LISA BETTINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:BETTINA
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 1:45 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-5529
Mailing Address - Country:US
Mailing Address - Phone:845-489-2570
Mailing Address - Fax:845-452-9338
Practice Address - Street 1:40 PARK LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528
Practice Address - Country:US
Practice Address - Phone:845-883-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049890-1104100000X
NY080145-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker