Provider Demographics
NPI:1053527333
Name:ROTH, WILLIAM C (LCSW)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:C
Last Name:ROTH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1349
Mailing Address - Country:US
Mailing Address - Phone:215-264-3187
Mailing Address - Fax:
Practice Address - Street 1:1219 RIDGE RD
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1349
Practice Address - Country:US
Practice Address - Phone:215-264-3187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0147681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA087539M0XMedicare PIN