Provider Demographics
NPI:1588537476
Name:ROTH, MARYBETH (LMSW)
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GOTHAM ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3239
Mailing Address - Country:US
Mailing Address - Phone:516-232-7745
Mailing Address - Fax:
Practice Address - Street 1:7559 263RD ST
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1150
Practice Address - Country:US
Practice Address - Phone:718-470-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122311104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty