Provider Demographics
NPI:1346308111
Name:ROTH, BIA KINSBRUNNER (LCSW)
Entity Type:Individual
Prefix:
First Name:BIA
Middle Name:KINSBRUNNER
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 KINDERKAMACK RD
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1870
Mailing Address - Country:US
Mailing Address - Phone:201-265-2033
Mailing Address - Fax:201-265-8272
Practice Address - Street 1:99 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1870
Practice Address - Country:US
Practice Address - Phone:201-265-2033
Practice Address - Fax:201-265-8272
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000332001041C0700X
NYPR004324-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ634487Medicare PIN