Provider Demographics
NPI:1770736217
Name:ROTH, CHRISTINE JOAN (MA SLP-CCC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:JOAN
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 VINCENT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1524
Mailing Address - Country:US
Mailing Address - Phone:646-261-0465
Mailing Address - Fax:
Practice Address - Street 1:1538 ROBERTSON PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-1132
Practice Address - Country:US
Practice Address - Phone:646-261-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist