Provider Demographics
NPI:1568945301
Name:ROTH, ANDREA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3049
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:607-753-0286
Practice Address - Street 1:165 MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:607-753-2086
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093814101Y00000X, 101YM0800X
NY093829101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid