Provider Demographics
NPI:1326428756
Name:ROTHMAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SW GRETCHEN TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1929
Mailing Address - Country:US
Mailing Address - Phone:203-988-9061
Mailing Address - Fax:
Practice Address - Street 1:1765 SW CAPTAINS PL
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1747
Practice Address - Country:US
Practice Address - Phone:772-266-8727
Practice Address - Fax:772-494-7093
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9350106E00000X
FLRBT-23-257740106S00000X
FL1-21-53700103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician