Provider Demographics
NPI:1245576859
Name:ROTTENBERG, SHIRA (SLP)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:ROTTENBERG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 1ST ST APT 403
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3368
Mailing Address - Country:US
Mailing Address - Phone:718-951-8800
Mailing Address - Fax:718-951-0846
Practice Address - Street 1:207 1ST ST APT 403
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3368
Practice Address - Country:US
Practice Address - Phone:718-951-8800
Practice Address - Fax:718-951-0846
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJTL-2208OtherLICENSE