Provider Demographics
NPI:1912593278
Name:ROTH, PATRICIA (MA, LCAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MA, LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 202ND ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2325
Mailing Address - Country:US
Mailing Address - Phone:917-225-6216
Mailing Address - Fax:
Practice Address - Street 1:236 E 82ND ST APT 1F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-2798
Practice Address - Country:US
Practice Address - Phone:917-225-6216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001650-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist