MEDICARE: RISA LORENA ROTH M.ED.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1861347080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RISA LORENA ROTH M.ED.

Provider Business Mailing Address
First Line	:	720 N 4TH ST UNIT 206
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55401-1945
Country	:	US
Telephone Number	:	847-962-1570
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 W LAKE ST STE 314
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2616
Country	:	US
Telephone Number	:	612-445-0225
Fax Number	:	612-445-0112

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

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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