Provider Demographics
NPI:1538243381
Name:PHELPS, ROGER D (PHD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:PHELPS
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 1:10 WATER ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6559
Mailing Address - Country:US
Mailing Address - Phone:207-861-3488
Mailing Address - Fax:207-861-3470
Practice Address - Street 1:10 WATER ST
Practice Address - Street 2:SUITE 306
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6559
Practice Address - Country:US
Practice Address - Phone:207-861-3488
Practice Address - Fax:207-861-3470
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS998103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME290410099Medicaid
MEMM8169Medicare ID - Type Unspecified