Provider Demographics
NPI:1912284894
Name:ROTH, MIRIAM (OTR)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 NEW MCNEIL AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1725
Mailing Address - Country:US
Mailing Address - Phone:516-242-5313
Mailing Address - Fax:718-504-7125
Practice Address - Street 1:1049 NEW MCNEIL AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1725
Practice Address - Country:US
Practice Address - Phone:516-242-5313
Practice Address - Fax:718-504-7125
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010423225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist