Provider Demographics
NPI:1780112003
Name:ROTH, AMBER (PT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3537
Practice Address - Street 1:112 INDEPENDENCE WAY STE 170
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:OH
Practice Address - Zip Code:43410-9811
Practice Address - Country:US
Practice Address - Phone:567-855-2807
Practice Address - Fax:567-855-2808
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist