Healthcare Provider Details

I. General information

NPI: 1780823245
Provider Name (Legal Business Name): LISA BETTINA ROTH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PARK LN
HIGHLAND NY
12528
US

IV. Provider business mailing address

45 SCENIC DR
POUGHKEEPSIE NY
12603-5529
US

V. Phone/Fax

Practice location:
  • Phone: 845-883-5151
  • Fax:
Mailing address:
  • Phone: 845-489-2570
  • Fax: 845-452-9338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number049890-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080145-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: