Provider Demographics
NPI:1205260569
Name:ROTH, ANNA LAURIE (MA LMHC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LAURIE
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 BANDANA BLVD N STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5126
Mailing Address - Country:US
Mailing Address - Phone:888-364-5977
Mailing Address - Fax:844-385-4630
Practice Address - Street 1:2265 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1737
Practice Address - Country:US
Practice Address - Phone:888-364-5977
Practice Address - Fax:844-385-4630
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60390532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health