Healthcare Provider Details

I. General information

NPI: 1104013564
Provider Name (Legal Business Name): CAROL K ROTHERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 JOHN YOUNG WAY STE 300 LIFE COUNSELING SERVICES
EXTON PA
19341-2567
US

IV. Provider business mailing address

PO BOX 158 1099 MARYLAND CIRCLE
DOWNINGTOWN PA
19335-0158
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-6464
  • Fax:
Mailing address:
  • Phone: 484-237-8477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC00-4271
License Number StatePA

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: