Provider Demographics
NPI:1306832027
Name:ROTH, ALEC (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALEC
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8890 W OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7235
Mailing Address - Country:US
Mailing Address - Phone:954-742-7032
Mailing Address - Fax:954-742-7868
Practice Address - Street 1:8890 W OAKLAND PARK BLVD
Practice Address - Street 2:SUITE #103
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7235
Practice Address - Country:US
Practice Address - Phone:954-742-7032
Practice Address - Fax:954-742-7868
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4866103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
59374Medicare ID - Type Unspecified