Healthcare Provider Details

I. General information

NPI: 1720453244
Provider Name (Legal Business Name): CARY EDWARD ROTHENBURGER III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BEACON ST.
BROOKLINE MA
02446
US

IV. Provider business mailing address

1980 COMMONWEALTH AVE APT 48
BRIGHTON MA
02135-5827
US

V. Phone/Fax

Practice location:
  • Phone: 617-278-0200
  • Fax:
Mailing address:
  • Phone: 617-610-4145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number219837
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: