Provider Demographics
NPI:1770259921
Name:ROTHENBERG, CARLY (LMSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ROTHENBERG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35501 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35501 MOUND RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4724
Practice Address - Country:US
Practice Address - Phone:248-470-8576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2023-12-04
Deactivation Date:2023-06-20
Deactivation Code:
Reactivation Date:2023-10-11
Provider Licenses
StateLicense IDTaxonomies
MI6801107179104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical