Provider Demographics
NPI:1881638690
Name:ROTH, MARK R (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W 106TH ST
Mailing Address - Street 2:STE 125-125
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7720
Mailing Address - Country:US
Mailing Address - Phone:317-459-6755
Mailing Address - Fax:
Practice Address - Street 1:333 N ALABAMA ST
Practice Address - Street 2:SUITE 350
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-2034
Practice Address - Country:US
Practice Address - Phone:317-459-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200045300Medicaid
IN200045300Medicaid
IN183380RRRRMedicare PIN