MEDICARE: DR. REBECCA ROTH PH.D.

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	103TC0700X	Clinical Psychologist	6301013498	MI

General Provider Information

NPI Number	:	1568659126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REBECCA ROTH PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 133
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-0133
Country	:	US
Telephone Number	:	231-340-9113
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 CHARLEVOIX RD STE 102
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-8421
Country	:	US
Telephone Number	:	231-340-9113
Fax Number	:	231-642-9116

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

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	04/22/2024

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Directions to “ DR. REBECCA ROTH PH.D.” Practice Location

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