Healthcare Provider Details

I. General information

NPI: 1316077860
Provider Name (Legal Business Name): EMILY ROTH JOHNSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY LEIGH ROTH

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LAKE STEEL STREET
GREEN LAKE WI
54941
US

IV. Provider business mailing address

PO BOX 588
GREEN LAKE WI
54941-0588
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-4070
  • Fax: 920-294-4139
Mailing address:
  • Phone: 920-294-4070
  • Fax: 920-294-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3349125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3349125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: