MEDICARE: LISA ROTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15821-132	WI
2	101YP2500X	Professional Counselor	1621-226	WI

General Provider Information

NPI Number	:	1447681168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ROTH

Provider Business Mailing Address
First Line	:	790 N MILWAUKEE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3724
Country	:	US
Telephone Number	:	262-706-5868
Fax Number	:	414-485-6843

Provider Business Practice Location Address
First Line	:	790 N MILWAUKEE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3724
Country	:	US
Telephone Number	:	262-706-5868
Fax Number	:	414-485-6843

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2013
Last Update Date	:	08/15/2022

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Directions to “ LISA ROTH ” Practice Location

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