MEDICARE: ELAINE RUTH ROTENBERG PH.D.

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	103TC0700X	Clinical Psychologist	PY4904	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PY4904	OTHER	FL	LICENSED CLINICAL PSYCH.

General Provider Information

NPI Number	:	1912989104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE RUTH ROTENBERG PH.D.

Provider Business Mailing Address
First Line	:	5841 CORPORATE WAY
Second Line	:	SUITE 200
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2039
Country	:	US
Telephone Number	:	561-684-1991
Fax Number	:	561-684-8582

Provider Business Practice Location Address
First Line	:	5841 CORPORATE WAY
Second Line	:	SUITE 200
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2039
Country	:	US
Telephone Number	:	561-684-1991
Fax Number	:	561-684-8582

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	11/05/2010

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