Provider Demographics
NPI:1417177932
Name:ROTH, BENNETT E (PHD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:E
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 1:161 WEST 15 ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6720
Mailing Address - Country:US
Mailing Address - Phone:212-255-0287
Mailing Address - Fax:
Practice Address - Street 1:161 WEST 15 ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6720
Practice Address - Country:US
Practice Address - Phone:212-255-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYD04515103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist