Provider Demographics
NPI:1689897506
Name:GODDARD, RODGER (PHD)
Entity Type:Individual
Prefix:DR
First Name:RODGER
Middle Name:
Last Name:GODDARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 W END RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1445
Mailing Address - Country:US
Mailing Address - Phone:973-763-0991
Mailing Address - Fax:
Practice Address - Street 1:359 W END RD
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1445
Practice Address - Country:US
Practice Address - Phone:973-763-0991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2597103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical