Provider Demographics
NPI:1972719623
Name:PLANTIKOW, ROGER WALLACE (DMIN)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WALLACE
Last Name:PLANTIKOW
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MORRIS AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1027
Mailing Address - Country:US
Mailing Address - Phone:973-376-6336
Mailing Address - Fax:973-376-7304
Practice Address - Street 1:500 MORRIS AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1027
Practice Address - Country:US
Practice Address - Phone:973-376-6336
Practice Address - Fax:973-376-7304
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
972101YP1600X
NJ37FI00038300106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral