Provider Demographics
NPI:1336224989
Name:ROTH, DONALD NORMAN (PSY D, APNP)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:NORMAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:PSY D, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 9TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-3216
Mailing Address - Country:US
Mailing Address - Phone:847-340-5785
Mailing Address - Fax:
Practice Address - Street 1:13500 WATERTOWN PLANK ROAD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2222
Practice Address - Country:US
Practice Address - Phone:847-340-5785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7902-33363LP0808X
WI2724-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health