Provider Demographics
NPI:1568502151
Name:KNUDSON, ROGER M (PH D)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:KNUDSON
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 1:631 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2047
Mailing Address - Country:US
Mailing Address - Phone:859-866-3962
Mailing Address - Fax:
Practice Address - Street 1:115 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1721
Practice Address - Country:US
Practice Address - Phone:513-523-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical