Healthcare Provider Details

I. General information

NPI: 1558056671
Provider Name (Legal Business Name): MANDY JO ROTH DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N 12TH AVE BLDG B
ARCADIA FL
34266-8752
US

IV. Provider business mailing address

2015 GRANT PL
MELBOURNE FL
32901-5600
US

V. Phone/Fax

Practice location:
  • Phone: 863-494-1242
  • Fax: 863-491-0466
Mailing address:
  • Phone: 314-856-2275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023006955
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11025764
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: