1942323100 NPI number — KIMBERLY LYNN ROTH M.A.

Table of content: KIMBERLY LYNN ROTH M.A. (NPI 1942323100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942323100 NPI number — KIMBERLY LYNN ROTH M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
KIMBERLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEONARD
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942323100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3584 ATLANTA HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWERY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-535-1050
Provider Business Mailing Address Fax Number:
678-943-8705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3584 ATLANTA HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWERY BRANCH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-535-1050
Provider Business Practice Location Address Fax Number:
678-943-8705
Provider Enumeration Date:
04/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LPC004836 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC004836 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: LPC004836 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)