Provider Demographics
NPI:1679508956
Name:ROEDER AND POLANSKY FAMILY AND CHILD ASSOCIATES
Entity Type:Organization
Organization Name:ROEDER AND POLANSKY FAMILY AND CHILD ASSOCIATES
Other - Org Name:HIEBEL AND ROEDER FAMILY AND CHILD ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:CLINICAL PSYCHOLOGIS
Authorized Official - Phone:860-347-9911
Mailing Address - Street 1:300 PLAZA MIDDLESEX
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-9911
Mailing Address - Fax:860-347-8120
Practice Address - Street 1:300 PLAZA MIDDLESEX
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-9911
Practice Address - Fax:860-347-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01297Medicare PIN