Provider Demographics
NPI:1346830395
Name:ROTH, ALEXANDRA JADE
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JADE
Last Name:ROTH
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 1:1719 HIMROD ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1479
Mailing Address - Country:US
Mailing Address - Phone:215-964-8034
Mailing Address - Fax:
Practice Address - Street 1:162 COURT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6445
Practice Address - Country:US
Practice Address - Phone:215-964-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist