Provider Demographics
NPI:1811417090
Name:ROTH, CHERYL K (LICDC-CS)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:ROTH
Suffix:
Gender:F
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3055
Mailing Address - Country:US
Mailing Address - Phone:330-298-9391
Mailing Address - Fax:330-298-9392
Practice Address - Street 1:246 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3055
Practice Address - Country:US
Practice Address - Phone:330-298-9391
Practice Address - Fax:330-298-9391
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC-923311101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty