MEDICARE: AMY MARIE ROTH MS, NCC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC7202	SD

General Provider Information

NPI Number	:	1538304324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY MARIE ROTH MS, NCC, LPC

Provider Business Mailing Address
First Line	:	1500 S SYCAMORE AVE STE 200
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-3711
Country	:	US
Telephone Number	:	605-838-8545
Fax Number	:	605-271-4155

Provider Business Practice Location Address
First Line	:	1500 S SYCAMORE AVE STE 200
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-3711
Country	:	US
Telephone Number	:	605-838-8545
Fax Number	:	605-271-4155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	10/11/2018

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