Provider Demographics
NPI:1245345032
Name:ROTH, KATHLEEN A (PT)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:4849 N MESA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5919
Mailing Address - Country:US
Mailing Address - Phone:915-351-6600
Mailing Address - Fax:915-351-6601
Practice Address - Street 1:8855 VISCOUNT BLVD STE E
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-5812
Practice Address - Country:US
Practice Address - Phone:915-593-8555
Practice Address - Fax:915-593-2422
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1039188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX062988302Medicaid
TX83402TOtherBLUECROSS AND BLUESHIELD
TX00W975Medicare PIN
TX062988302Medicaid