Provider Demographics
NPI:1790201499
Name:ROTH, AMY ELISE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELISE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CENTRAL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-2124
Mailing Address - Country:US
Mailing Address - Phone:203-314-5349
Mailing Address - Fax:
Practice Address - Street 1:308 RACEBROOK ROAD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477
Practice Address - Country:US
Practice Address - Phone:203-920-1885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT005650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program