Provider Demographics
NPI:1871038422
Name:ROTH, DIANE (MED CGS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MED CGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 POST OFFICE SQ
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-3207
Mailing Address - Country:US
Mailing Address - Phone:508-823-5291
Mailing Address - Fax:508-823-5906
Practice Address - Street 1:4 POST OFFICE SQ
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-3207
Practice Address - Country:US
Practice Address - Phone:508-823-5291
Practice Address - Fax:508-823-5906
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional