Provider Demographics
NPI:1477656098
Name:BASH, ROGER L (PH D)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:BASH
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10070 DAPHNE AVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:561-622-1678
Mailing Address - Fax:561-799-5902
Practice Address - Street 1:10301 HAGEN RANCH RD STE B6
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3723
Practice Address - Country:US
Practice Address - Phone:561-752-9490
Practice Address - Fax:561-752-9491
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4544103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54179Medicare ID - Type Unspecified