Provider Demographics
NPI:1679810774
Name:ROTH, ADAM (PHD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 MILTON RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4616
Mailing Address - Country:US
Mailing Address - Phone:216-225-8376
Mailing Address - Fax:
Practice Address - Street 1:21403 CHAGRIN BLVD
Practice Address - Street 2:210
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5322
Practice Address - Country:US
Practice Address - Phone:216-225-8376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6920103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist