Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 0720000081 | VT |
NPI | 1124289640 |
---|---|
Provider Name | Mr. Gary L Roth |
First Address | Killington, VT 05751-9476 |
Second Address | Killington, VT 05751-9476 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2008 |
Last Update Date | 18/06/2008 |