Provider Demographics
NPI:1730284688
Name:ROEDING, GINNA M (PHD)
Entity Type:Individual
Prefix:
First Name:GINNA
Middle Name:M
Last Name:ROEDING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1506
Mailing Address - Country:US
Mailing Address - Phone:518-489-4431
Mailing Address - Fax:518-489-5189
Practice Address - Street 1:790 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1506
Practice Address - Country:US
Practice Address - Phone:518-489-4431
Practice Address - Fax:518-489-5189
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011101103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01700201Medicaid
NY54112EMedicare ID - Type Unspecified