Provider Demographics
NPI:1922509397
Name:ROTH, SAMANTHA (LGSW)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3036
Mailing Address - Country:US
Mailing Address - Phone:757-320-9356
Mailing Address - Fax:
Practice Address - Street 1:10705 CHARTER DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2800
Practice Address - Country:US
Practice Address - Phone:757-320-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22974104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker