Provider Demographics
NPI:1457772113
Name:ROTBERG, MOSHE
Entity Type:Individual
Prefix:
First Name:MOSHE
Middle Name:
Last Name:ROTBERG
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 1:158 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5854
Mailing Address - Country:US
Mailing Address - Phone:732-779-1360
Mailing Address - Fax:
Practice Address - Street 1:158 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5854
Practice Address - Country:US
Practice Address - Phone:732-779-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05700100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker