Healthcare Provider Details

I. General information

NPI: 1407348048
Provider Name (Legal Business Name): OLIVIA ROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 CHAIN BRIDGE RD
FAIRFAX VA
22030-2793
US

IV. Provider business mailing address

3541 CHAIN BRIDGE RD STE 204
FAIRFAX VA
22030-2793
US

V. Phone/Fax

Practice location:
  • Phone: 703-218-6599
  • Fax:
Mailing address:
  • Phone: 703-218-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: