Healthcare Provider Details

I. General information

NPI: 1225793078
Provider Name (Legal Business Name): JONATHAN ROTENBERG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 11/06/2021
Certification Date: 11/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SOUTH ST
CHESTNUT HILL MA
02467-3694
US

IV. Provider business mailing address

24 MARLBOROUGH ST
BOSTON MA
02116-2164
US

V. Phone/Fax

Practice location:
  • Phone: 617-469-0300
  • Fax:
Mailing address:
  • Phone: 617-247-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number226994
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: