Provider Demographics
NPI:1992924047
Name:LIGHT, ROGER KENNETH (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:KENNETH
Last Name:LIGHT
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 1:509 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6746
Mailing Address - Country:US
Mailing Address - Phone:310-374-1221
Mailing Address - Fax:310-214-0648
Practice Address - Street 1:509 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6746
Practice Address - Country:US
Practice Address - Phone:310-374-1221
Practice Address - Fax:310-214-0648
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9830103G00000X
HIPSY819103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist