Provider Demographics
NPI:1447628045
Name:ROLE, MARUSSIA ROTHENBERG (PSYD)
Entity type:Individual
Prefix:
First Name:MARUSSIA
Middle Name:ROTHENBERG
Last Name:ROLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411A HIGHLAND AVE
Mailing Address - Street 2:BOX 378
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2516
Mailing Address - Country:US
Mailing Address - Phone:617-418-1286
Mailing Address - Fax:
Practice Address - Street 1:11 BEECH ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140
Practice Address - Country:US
Practice Address - Phone:617-418-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11137103TC0700X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty