Provider Demographics
NPI:1174916266
Name:ROTHMAN, DANIEL JACOB (MA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JACOB
Last Name:ROTHMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340
Mailing Address - Country:US
Mailing Address - Phone:208-471-4838
Mailing Address - Fax:
Practice Address - Street 1:220 RIVER ST E
Practice Address - Street 2:SUITE D
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-471-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID7227OtherLCPC