Provider Demographics
NPI:1063450245
Name:ROEDER, GREGORY D (PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:ROEDER
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 1:200 WHITE SPRUCE BLVD
Mailing Address - Street 2:SUITE 134
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1605
Mailing Address - Country:US
Mailing Address - Phone:585-427-0270
Mailing Address - Fax:585-427-0270
Practice Address - Street 1:200 WHITE SPRUCE BLVD
Practice Address - Street 2:SUITE 134
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1605
Practice Address - Country:US
Practice Address - Phone:585-427-0270
Practice Address - Fax:585-427-0270
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0084561103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010008456OtherEXCELLUS BCBS ROCHESTER
NY13071OtherMONROE PLAN
NYP100267OtherPREFERRED CARE