Provider Demographics
NPI:1992866735
Name:ROTH, SAMUEL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 EAST BELTLINE SE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-831-2000
Mailing Address - Fax:616-831-2001
Practice Address - Street 1:1550 EAST BELTLINE SE
Practice Address - Street 2:SUITE 340
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-831-2000
Practice Address - Fax:616-831-2001
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist