Provider Demographics
NPI:1295284644
Name:ROTH, LAURIE M (MFT)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 KENTUCKY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2324
Mailing Address - Country:US
Mailing Address - Phone:707-778-8414
Mailing Address - Fax:
Practice Address - Street 1:159 KENTUCKY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2305
Practice Address - Country:US
Practice Address - Phone:707-778-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25807101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC25807OtherMARRIAGE AND FAMILY THERAPY