=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790353019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KARLA ROTH COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2021
-----------------------------------------------------
Last Update Date | 06/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 COMMERCE DR
-----------------------------------------------------
City | HESSTON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67062-8938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-869-9986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 COMMERCE DR
-----------------------------------------------------
City | HESSTON
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67062-8938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-869-9986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | ADRIA ESTES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-269-0689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------