Provider Demographics
NPI:1932854031
Name:ROTH, SHARON (MS)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 SW COLWELL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2758
Mailing Address - Country:US
Mailing Address - Phone:808-765-5724
Mailing Address - Fax:
Practice Address - Street 1:160 NW CENTRAL PARK PLZ STE 110
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1825
Practice Address - Country:US
Practice Address - Phone:772-361-6778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLIMH22074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty