Basic Information
Provider Information | |||||||||
NPI: | 1902246606 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROTHBERG | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW, LCDC, MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DAVIS-DENIZ | ||||||||
OtherFirstName: | ASHLEY | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 700 N SAM HOUSTON PKWY W | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770674338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8328281005 | ||||||||
FaxNumber: | 8328250264 | ||||||||
Practice Location | |||||||||
Address1: | 2218 KINBROOK DR | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770776115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8324522503 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2013 | ||||||||
LastUpdateDate: | 06/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11714 | TX | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 55355 | TX | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
No ID Information.