Provider Demographics
NPI:1831123322
Name:ROTH, KEVIN HOWARD (LMFT,CAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:HOWARD
Last Name:ROTH
Suffix:
Gender:M
Credentials:LMFT,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 FETTERS MILL ROAD
Mailing Address - Street 2:PO BOX 3
Mailing Address - City:BRYN ATHYN
Mailing Address - State:PA
Mailing Address - Zip Code:19009
Mailing Address - Country:US
Mailing Address - Phone:215-947-3413
Mailing Address - Fax:215-947-0818
Practice Address - Street 1:885 FETTERS MILL ROAD
Practice Address - Street 2:
Practice Address - City:BRYN ATHYN
Practice Address - State:PA
Practice Address - Zip Code:19009
Practice Address - Country:US
Practice Address - Phone:215-947-3413
Practice Address - Fax:215-947-0818
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF000126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health