Provider Demographics
NPI:1821663006
Name:ROTH, RILEY NOELLE
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:NOELLE
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20302 43RD AVE E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-6718
Mailing Address - Country:US
Mailing Address - Phone:253-682-9519
Mailing Address - Fax:
Practice Address - Street 1:1816 EAGLE DR STE 100-C
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8273
Practice Address - Country:US
Practice Address - Phone:770-516-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA7366225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant