Provider Demographics
NPI:1437265568
Name:MAITLAND, ROGER (PHD PSYCHOLOGY)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:MAITLAND
Suffix:
Gender:M
Credentials:PHD PSYCHOLOGY
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:MAITLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 885
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066
Mailing Address - Country:US
Mailing Address - Phone:732-381-6118
Mailing Address - Fax:732-381-3491
Practice Address - Street 1:999 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066
Practice Address - Country:US
Practice Address - Phone:732-381-6118
Practice Address - Fax:732-381-3491
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2387103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ536498Medicare ID - Type Unspecified