Provider Demographics
NPI:1790034072
Name:ALLEN ROTH EDUCATIONAL AND PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:ALLEN ROTH EDUCATIONAL AND PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-378-5641
Mailing Address - Street 1:36 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3440
Mailing Address - Country:US
Mailing Address - Phone:973-378-5641
Mailing Address - Fax:973-762-0045
Practice Address - Street 1:36 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3440
Practice Address - Country:US
Practice Address - Phone:973-378-5641
Practice Address - Fax:973-762-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-02
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00375000103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty