Provider Demographics
NPI:1164589347
Name:RODEN, DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:RODEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MINERVA AVE
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-3118
Mailing Address - Country:US
Mailing Address - Phone:732-946-3030
Mailing Address - Fax:732-946-4891
Practice Address - Street 1:22 MINERVA AVE
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-3118
Practice Address - Country:US
Practice Address - Phone:732-946-3030
Practice Address - Fax:732-946-4891
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05216500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0047732Medicaid