Provider Demographics
NPI:1518276500
Name:ROTHFRITZ, MARIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIAM
Middle Name:
Last Name:ROTHFRITZ
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 1:4 FOWLER PL
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9435
Mailing Address - Country:US
Mailing Address - Phone:973-978-7188
Mailing Address - Fax:
Practice Address - Street 1:1135 CLIFTON AVE STE 207
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3643
Practice Address - Country:US
Practice Address - Phone:973-988-4241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00496700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03290993Medicaid