Provider Demographics
NPI:1245866433
Name:ROTH, BARBARA EDESON (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:EDESON
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CHESTNUT ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-3140
Mailing Address - Country:US
Mailing Address - Phone:914-565-9677
Mailing Address - Fax:
Practice Address - Street 1:THE NATHANIEL WITHERELL HOME
Practice Address - Street 2:70 PARSONAGE ROAD
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-618-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004069-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty