Healthcare Provider Details

I. General information

NPI: 1497842322
Provider Name (Legal Business Name): JEFF ROTHENBERG LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HEATON ST
MONTPELIER VT
05602-2489
US

IV. Provider business mailing address

149 HOWES RD
MORETOWN VT
05660-4412
US

V. Phone/Fax

Practice location:
  • Phone: 802-223-6328
  • Fax: 802-229-8004
Mailing address:
  • Phone: 802-496-2699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068.0000507
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: