Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 35SI00375000 | NJ |
Y | 103TC0700X | Clinical Psychologist | 35SI00375000 | NJ |
NPI | 1013055649 |
---|---|
Provider Name | Andrew Roth |
First Address | South Orange, NJ 07079-2409 |
Second Address | Montclair, NJ 07042-3439 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2007 |
Last Update Date | 10/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S84611 | (02) | NJ |