Provider Demographics
NPI:1427177211
Name:ROTH, THEODORE MARTIN (PHD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:MARTIN
Last Name:ROTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 ASHFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-2626
Mailing Address - Country:US
Mailing Address - Phone:914-674-0573
Mailing Address - Fax:914-631-4928
Practice Address - Street 1:369 ASHFORD AVENUE
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-2626
Practice Address - Country:US
Practice Address - Phone:914-674-0573
Practice Address - Fax:914-631-4928
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0074101103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0011039OtherGHI
NY02035798Medicaid
NYP392307OtherOXFORD
NY065848OtherVALUE OPTIONS