Provider Demographics
NPI:1023577533
Name:ROOTH, NICOLE (NCC, LPC, LCADC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROOTH
Suffix:
Gender:F
Credentials:NCC, LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3903
Mailing Address - Country:US
Mailing Address - Phone:201-315-2746
Mailing Address - Fax:
Practice Address - Street 1:187 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4140
Practice Address - Country:US
Practice Address - Phone:732-410-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00262400101YA0400X
NJ37PC00587600101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional