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General NPI Number Information
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NPI Number | 1649503327
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Entity Type | Organization
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Legal Business Name | KRISTIANSSON ROTH PC
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Dates
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Enumeration Date | 09/11/2009
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Last Update Date | 09/11/2009
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Provider Practice Location Address
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Address Line | 4445 HWY 40 SATURDAY PARK 503
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City | SAINT MARYS
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State | GA
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Zip | 31558-4099
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Country | US
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Telephone | 912-409-9879
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Fax |
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Provider Business Mailing Address
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Address Line | 4445 HWY 40 SATURDAY PARK 503
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City | SAINT MARYS
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State | GA
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Zip | 31558-4099
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. KRISTIANSSON ROTH
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Credential | PHD
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Telephone | 912-409-9879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY002706
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License Number State | GA
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