Healthcare Provider Details

I. General information

NPI: 1366565913
Provider Name (Legal Business Name): JONATHAN ROTH LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N AURORA ST STE 4
ITHACA NY
14850-4230
US

IV. Provider business mailing address

PO BOX 6632
ITHACA NY
14851-6632
US

V. Phone/Fax

Practice location:
  • Phone: 415-564-5117
  • Fax: 607-327-5514
Mailing address:
  • Phone: 415-564-5117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005266
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number86401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: