Provider Demographics
NPI:1447681168
Name:ROTH, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3724
Mailing Address - Country:US
Mailing Address - Phone:262-706-5868
Mailing Address - Fax:414-485-6843
Practice Address - Street 1:790 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3724
Practice Address - Country:US
Practice Address - Phone:262-706-5868
Practice Address - Fax:414-485-6843
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15821-132101YA0400X
WI1621-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)