Provider Demographics
NPI:1821472721
Name:MICHELE M ROTH MS LPC LLC
Entity Type:Organization
Organization Name:MICHELE M ROTH MS LPC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:L.P.C.
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:856-297-9689
Mailing Address - Street 1:15 W DEHART AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08312-2458
Mailing Address - Country:US
Mailing Address - Phone:856-297-9689
Mailing Address - Fax:856-243-2456
Practice Address - Street 1:3288 DELSEA DR STE D
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08322-3165
Practice Address - Country:US
Practice Address - Phone:856-297-9689
Practice Address - Fax:856-243-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00324400251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health