Provider Demographics
NPI:1275126237
Name:ROTHMAN, ALISA J
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:J
Last Name:ROTHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-1818
Mailing Address - Country:US
Mailing Address - Phone:510-229-2007
Mailing Address - Fax:
Practice Address - Street 1:166 SANTA CLARA AVE STE 205
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1323
Practice Address - Country:US
Practice Address - Phone:510-601-1929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT124394106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist