Provider Demographics
NPI:1164846754
Name:ROTH, SEAN DAVID (MFTI MA)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:DAVID
Last Name:ROTH
Suffix:
Gender:M
Credentials:MFTI MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 TOPANGA CYN. BLVD. #C105
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367
Mailing Address - Country:US
Mailing Address - Phone:818-943-6933
Mailing Address - Fax:
Practice Address - Street 1:22020 CLARENDON STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367
Practice Address - Country:US
Practice Address - Phone:818-812-5871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist