Provider Demographics
NPI:1265489611
Name:ROTH, JOAN (PHD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-1801
Mailing Address - Country:US
Mailing Address - Phone:800-725-6280
Mailing Address - Fax:800-725-6380
Practice Address - Street 1:25 BIALYSTOKER PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4008
Practice Address - Country:US
Practice Address - Phone:212-673-8500
Practice Address - Fax:212-353-9471
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical