Provider Demographics
NPI:1922351261
Name:ROTH, LAUREN ROSE (MA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ROSE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E ROBINSON ST
Mailing Address - Street 2:#1811
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1695
Mailing Address - Country:US
Mailing Address - Phone:407-738-9776
Mailing Address - Fax:
Practice Address - Street 1:2479 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2541
Practice Address - Country:US
Practice Address - Phone:407-657-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health