Healthcare Provider Details

I. General information

NPI: 1134107816
Provider Name (Legal Business Name): ROBERTA ROTH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 SPYGLASS DR
EUGENE OR
97401-2089
US

IV. Provider business mailing address

553 SPYGLASS DRIVE DRIVE
EUGENE OR
97401
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-6986
  • Fax: 541-484-6986
Mailing address:
  • Phone: 541-484-6986
  • Fax: 541-484-6986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number000174
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: