Provider Demographics
NPI:1720096811
Name:ROTH, STEVEN D (ATC/LAT)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:D
Last Name:ROTH
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1423
Mailing Address - Country:US
Mailing Address - Phone:708-906-8985
Mailing Address - Fax:708-460-8788
Practice Address - Street 1:15635 S 94TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4722
Practice Address - Country:US
Practice Address - Phone:708-460-8588
Practice Address - Fax:708-460-8788
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer