Healthcare Provider Details

I. General information

NPI: 1154179414
Provider Name (Legal Business Name): JUDITH E. ROTH LCSW, LMFT, PSY D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 VIA DE LA VALLE SUITE 311E
DEL MAR CA
92014-4248
US

IV. Provider business mailing address

P.O. BOX 9674
RANCHO SANTA FE CA
92067-4674
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-0381
  • Fax:
Mailing address:
  • Phone: 858-336-5427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMC16584
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLH10543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: