Provider Demographics
NPI:1174518476
Name:ROTH, SUSAN S (LCSW DCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:S
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 N PEARY ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-5355
Mailing Address - Country:US
Mailing Address - Phone:703-516-0304
Mailing Address - Fax:703-516-0305
Practice Address - Street 1:3107 N PEARY ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-5355
Practice Address - Country:US
Practice Address - Phone:703-516-0304
Practice Address - Fax:703-516-0305
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA09040006911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
78400590OtherUBH
2454001OtherBCBS
650846Medicare ID - Type Unspecified