MEDICARE: JEFFREY ROTH PHD PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	B1-0000251	DE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598886558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY ROTH PHD PSYCHOLOGY

Provider Business Mailing Address
First Line	:	240 N JAMES ST
Second Line	:	SUITES 104-106
City	:	WILMINGTON
State	:	DE
Zip	:	19804-3169
Country	:	US
Telephone Number	:	302-633-0301
Fax Number	:	302-633-0331

Provider Business Practice Location Address
First Line	:	240 N JAMES ST
Second Line	:	SUITES 104-106
City	:	WILMINGTON
State	:	DE
Zip	:	19804-3169
Country	:	US
Telephone Number	:	302-633-0301
Fax Number	:	302-633-0331

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/09/2007

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