Provider Demographics
NPI:1629007877
Name:ROTHFUSS, MARK W (LCMFT, LMAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:ROTHFUSS
Suffix:
Gender:M
Credentials:LCMFT, LMAC
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 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:207 N MILL ST STE 5
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420
Practice Address - Country:US
Practice Address - Phone:785-738-5363
Practice Address - Fax:785-738-6471
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS457101YA0400X
KS327106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200450820AMedicaid
KS856675OtherBCBS
11655335OtherCAQH
KS818-3624OtherCONSORTIUM