Provider Demographics
NPI:1649034752
Name:ROTH, MALKA (BCBA)
Entity type:Individual
Prefix:
First Name:MALKA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WHITE DOVE CT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5167
Mailing Address - Country:US
Mailing Address - Phone:929-327-0820
Mailing Address - Fax:
Practice Address - Street 1:1 WHITE DOVE CT
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5167
Practice Address - Country:US
Practice Address - Phone:929-327-0820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-24-70750103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst