Provider Demographics
NPI:1063400422
Name:MADER, LOTHAR ENGELBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:LOTHAR
Middle Name:ENGELBERT
Last Name:MADER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3738
Mailing Address - Country:US
Mailing Address - Phone:916-782-2100
Mailing Address - Fax:916-624-0701
Practice Address - Street 1:2130 PROFESSIONAL DR
Practice Address - Street 2:SUITE 240
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3738
Practice Address - Country:US
Practice Address - Phone:916-782-2100
Practice Address - Fax:916-624-0701
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8474103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7366414Medicaid
00PL84740Medicare UPIN