Provider Demographics
NPI:1750171153
Name:ROTH, MELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:ROTH
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 W GRASSY PLAIN DR
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-6739
Mailing Address - Country:US
Mailing Address - Phone:801-824-2750
Mailing Address - Fax:
Practice Address - Street 1:2317 N HILL FIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4782
Practice Address - Country:US
Practice Address - Phone:801-525-4645
Practice Address - Fax:801-643-5619
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371425-3501101YM0800X, 101YP2500X, 1041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool