Basic Information
Provider Information | |||||||||
NPI: | 1629007877 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTHFUSS | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCMFT, LMAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 747 | ||||||||
Address2: |   | ||||||||
City: | MANHATTAN | ||||||||
State: | KS | ||||||||
PostalCode: | 665050747 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7855874300 | ||||||||
FaxNumber: | 7855874377 | ||||||||
Practice Location | |||||||||
Address1: | 207 N MILL ST STE 5 | ||||||||
Address2: |   | ||||||||
City: | BELOIT | ||||||||
State: | KS | ||||||||
PostalCode: | 67420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7857385363 | ||||||||
FaxNumber: | 7857386471 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2006 | ||||||||
LastUpdateDate: | 08/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 457 | KS | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 327 | KS | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 200450820A | 05 | KS |   | MEDICAID | 856675 | 01 | KS | BCBS | OTHER | 11655335 | 01 |   | CAQH | OTHER | 818-3624 | 01 | KS | CONSORTIUM | OTHER |