Healthcare Provider Details

I. General information

NPI: 1467606392
Provider Name (Legal Business Name): MARY DEBORAH ROTH R.D.L.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 216B STE 216B
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

3009 N BALLAS RD STE 216B STE 216B
SAINT LOUIS MO
63131-2322
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-4351
  • Fax: 314-996-4591
Mailing address:
  • Phone: 314-996-4351
  • Fax: 314-996-4591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2001016361
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: