Provider Demographics
NPI:1932977543
Name:ROTH, ADDISON
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 VIENTO CIR APT E
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1426
Mailing Address - Country:US
Mailing Address - Phone:678-230-6008
Mailing Address - Fax:
Practice Address - Street 1:5916 ANAHEIM AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1894
Practice Address - Country:US
Practice Address - Phone:505-291-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker