Provider Demographics
NPI:1245454636
Name:ROTH, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 GAULT ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2590
Mailing Address - Country:US
Mailing Address - Phone:831-566-7273
Mailing Address - Fax:
Practice Address - Street 1:4113 SCOTTS VALLEY DR STE 212
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4547
Practice Address - Country:US
Practice Address - Phone:831-566-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health