Provider Demographics
NPI:1942483854
Name:ROTH, KATHARINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 S 900 E STE 103
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7266
Mailing Address - Country:US
Mailing Address - Phone:801-872-5516
Mailing Address - Fax:801-212-9942
Practice Address - Street 1:5383 S 900 E STE 103
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7266
Practice Address - Country:US
Practice Address - Phone:801-872-5516
Practice Address - Fax:801-212-9942
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1612089211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065879Medicare PIN