Provider Demographics
NPI:1467411512
Name:ROTH-HAUPTMAN, JAN L (PHD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:ROTH-HAUPTMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E 24TH ST
Mailing Address - Street 2:APT. 6C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4011
Mailing Address - Country:US
Mailing Address - Phone:212-686-5116
Mailing Address - Fax:
Practice Address - Street 1:305 E 24TH ST
Practice Address - Street 2:APT. 6C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4011
Practice Address - Country:US
Practice Address - Phone:212-686-5116
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01257996Medicaid