Provider Demographics
NPI:1023105756
Name:ROTH, DALE LEON (MDV DAVIS LMHP LAPC)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:LEON
Last Name:ROTH
Suffix:
Gender:M
Credentials:MDV DAVIS LMHP LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S 13TH STREET
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701
Mailing Address - Country:US
Mailing Address - Phone:402-370-3140
Mailing Address - Fax:402-370-3370
Practice Address - Street 1:4432 SUNRISE PLACE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601
Practice Address - Country:US
Practice Address - Phone:402-564-9994
Practice Address - Fax:402-562-6458
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE562101YA0400X
NE2512101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
97061OtherBCBS AUX
85330OtherBCBS