Provider Demographics
NPI:1134129307
Name:ROTHMAN, KENNETH MICHAEL (D,ED)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:D,ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 E INDIANTOWN RD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-5104
Mailing Address - Country:US
Mailing Address - Phone:561-575-0323
Mailing Address - Fax:561-575-0323
Practice Address - Street 1:1061 E INDIANTOWN RD
Practice Address - Street 2:SUITE 311
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5104
Practice Address - Country:US
Practice Address - Phone:561-575-0323
Practice Address - Fax:561-575-0323
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2560103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73738OtherBCBS