Provider Demographics
NPI:1831214667
Name:ROTH, ELLEN FAYE (EDD)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:FAYE
Last Name:ROTH
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 PARK ST
Mailing Address - Street 2:UNIT 9B
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1735
Mailing Address - Country:US
Mailing Address - Phone:973-822-0251
Mailing Address - Fax:973-822-0814
Practice Address - Street 1:38 PARK ST
Practice Address - Street 2:UNIT 9B
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1735
Practice Address - Country:US
Practice Address - Phone:973-822-0251
Practice Address - Fax:973-822-0814
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ01883103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
615772Medicare ID - Type Unspecified