Provider Demographics
NPI:1154179414
Name:ROTH, JUDITH E (LCSW, LMFT, PSY D)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:E
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW, LMFT, PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9674
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-4674
Mailing Address - Country:US
Mailing Address - Phone:858-336-5427
Mailing Address - Fax:
Practice Address - Street 1:3790 VIA DE LA VALLE
Practice Address - Street 2:SUITE 311E
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-4248
Practice Address - Country:US
Practice Address - Phone:858-755-0381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
CAMC16584106H00000X
CALH105431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist