Provider Demographics
NPI:1134407562
Name:ROTHENBERG, DANIEL KEITH
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:KEITH
Last Name:ROTHENBERG
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 1:6274 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2674
Mailing Address - Country:US
Mailing Address - Phone:503-333-8988
Mailing Address - Fax:
Practice Address - Street 1:6274 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2674
Practice Address - Country:US
Practice Address - Phone:503-333-8988
Practice Address - Fax:971-275-1222
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW650371041C0700X
ORL73071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL