Healthcare Provider Details

I. General information

NPI: 1093895088
Provider Name (Legal Business Name): FLO B ROTH MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W FONTAINE WAY
FARMINGDALE NJ
07727-4355
US

IV. Provider business mailing address

3 W FONTAINE WAY
FARMINGDALE NJ
07727-4355
US

V. Phone/Fax

Practice location:
  • Phone: 732-496-8030
  • Fax: 732-292-1888
Mailing address:
  • Phone: 732-308-5505
  • Fax: 732-292-1888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC04019
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: