Provider Demographics
NPI:1689355281
Name:ROTH-HAWTHORNE, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:ROTH-HAWTHORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 67TH AVE APT 8J
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4928
Mailing Address - Country:US
Mailing Address - Phone:510-393-3215
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4527
Practice Address - Country:US
Practice Address - Phone:212-828-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health