Provider Demographics
NPI:1194747469
Name:ROEDER, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ROEDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2111
Mailing Address - Country:US
Mailing Address - Phone:315-361-8413
Mailing Address - Fax:315-361-8450
Practice Address - Street 1:201 CEDAR ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2111
Practice Address - Country:US
Practice Address - Phone:315-361-8413
Practice Address - Fax:315-361-8450
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC-042014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional