Basic Information
| Provider Information | |||||||||
| NPI: | 1023123106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTHMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 EAST 12TH ST | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126332900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 NATHAN D PERLMAN PL | ||||||||
| Address2: | 2 BERNSTEIN PAV | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100033851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124202400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 015565 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 015565-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02462297 | 05 | NY | MEDICAID |