Provider Demographics
NPI:1851483358
Name:ROTH, MARY C (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:ROTH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 SCARSDALE RD
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-1659
Mailing Address - Country:US
Mailing Address - Phone:912-492-8061
Mailing Address - Fax:
Practice Address - Street 1:575 SCARSDALE RD
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-1659
Practice Address - Country:US
Practice Address - Phone:912-492-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005962235Z00000X
NY021026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA647207864AMedicaid