Healthcare Provider Details

I. General information

NPI: 1720254857
Provider Name (Legal Business Name): STEPHANIE L ROTH LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5710 N BROADWAY ST
CHICAGO IL
60660-4302
US

IV. Provider business mailing address

5710 N BROADWAY ST
CHICAGO IL
60660-4302
US

V. Phone/Fax

Practice location:
  • Phone: 773-728-1000
  • Fax:
Mailing address:
  • Phone: 773-728-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.006723
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: