Provider Demographics
NPI:1699765933
Name:ROTH, STEFANIE RACHEL (LCSW)
Entity type:Individual
Prefix:MS
First Name:STEFANIE
Middle Name:RACHEL
Last Name:ROTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BAR BEACH RD
Mailing Address - Street 2:PORT WASHINGTON
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4003
Mailing Address - Country:US
Mailing Address - Phone:516-883-1151
Mailing Address - Fax:
Practice Address - Street 1:112 FRANKLYN PLACE
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1217
Practice Address - Country:US
Practice Address - Phone:516-374-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059353-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1699765933Medicaid
NY1699765933Medicaid