MEDICARE: MS. SAMANTHA ROTH LGSW

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	104100000X	Social Worker	22974	MD

General Provider Information

NPI Number	:	1922509397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SAMANTHA ROTH LGSW

Provider Business Mailing Address
First Line	:	2004 EASTERN AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21231-3036
Country	:	US
Telephone Number	:	757-320-9356
Fax Number	:

Provider Business Practice Location Address
First Line	:	10705 CHARTER DR STE 410
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-2800
Country	:	US
Telephone Number	:	757-320-9356
Fax Number	:

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

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	02/21/2018

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