Healthcare Provider Details

I. General information

NPI: 1164404687
Provider Name (Legal Business Name): KARLA BOSHART ROTH LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 COMMERCE DR
HESSTON KS
67062-8938
US

IV. Provider business mailing address

114 COMMERCE DR
HESSTON KS
67062-8938
US

V. Phone/Fax

Practice location:
  • Phone: 620-869-9986
  • Fax: 609-869-9046
Mailing address:
  • Phone: 620-869-9986
  • Fax: 609-869-9046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1901
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: