Provider Demographics
NPI:1699263327
Name:MITCHELL ROTH
Entity type:Organization
Organization Name:MITCHELL ROTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:561-740-5642
Mailing Address - Street 1:200 KNUTH RD STE 254
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4637
Mailing Address - Country:US
Mailing Address - Phone:561-740-5642
Mailing Address - Fax:
Practice Address - Street 1:200 KNUTH RD STE 254
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4637
Practice Address - Country:US
Practice Address - Phone:561-740-5642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty