Healthcare Provider Details

I. General information

NPI: 1841211745
Provider Name (Legal Business Name): LORRAINE SHARON ROTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6178 EDSALL RD APT. #96
ALEXANDRIA VA
22304-5881
US

IV. Provider business mailing address

6178 EDSALL RD APT. #96
ALEXANDRIA VA
22304-5809
US

V. Phone/Fax

Practice location:
  • Phone: 571-970-2406
  • Fax:
Mailing address:
  • Phone: 571-970-2406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number24614
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number036-079508
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-079508
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24614
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: