Provider Demographics
NPI:1316735459
Name:ROTH, RACHEL
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:ROTH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 BELMAR DR W
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5947
Mailing Address - Country:US
Mailing Address - Phone:646-644-9943
Mailing Address - Fax:
Practice Address - Street 1:80 BELMAR DR W
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5947
Practice Address - Country:US
Practice Address - Phone:646-644-9943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004223-01103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst