Provider Demographics
NPI:1992389605
Name:ROTH, JULIE (LCPC)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MAPLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-1121
Mailing Address - Country:US
Mailing Address - Phone:309-712-6396
Mailing Address - Fax:
Practice Address - Street 1:208 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2044
Practice Address - Country:US
Practice Address - Phone:309-585-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-09
Last Update Date:2021-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional