Healthcare Provider Details

I. General information

NPI: 1134129307
Provider Name (Legal Business Name): KENNETH MICHAEL ROTHMAN D,ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 E INDIANTOWN RD SUITE 311
JUPITER FL
33477-5104
US

IV. Provider business mailing address

1061 E INDIANTOWN RD SUITE 311
JUPITER FL
33477-5104
US

V. Phone/Fax

Practice location:
  • Phone: 561-575-0323
  • Fax: 561-575-0323
Mailing address:
  • Phone: 561-575-0323
  • Fax: 561-575-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY2560
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY2560
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: