Provider Demographics
NPI:1356443352
Name:ROTHENBERG, STEPHEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:ROTHENBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170809
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02117-1039
Mailing Address - Country:US
Mailing Address - Phone:617-274-8734
Mailing Address - Fax:
Practice Address - Street 1:10 NEWBURY ST # 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3204
Practice Address - Country:US
Practice Address - Phone:617-274-8734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002366Medicare UPIN
MA64124Medicare UPIN
MA709304Medicare UPIN
MAW03353Medicare UPIN