Provider Demographics
NPI:1386114015
Name:ROTH, BRADLEY WILLIAM (LMFT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:ROTH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 CRESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-6923
Mailing Address - Country:US
Mailing Address - Phone:203-877-3600
Mailing Address - Fax:
Practice Address - Street 1:57 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-6923
Practice Address - Country:US
Practice Address - Phone:203-888-0462
Practice Address - Fax:203-888-1465
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT27.002034101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health