Provider Demographics
NPI:1871681221
Name:ROANOKE PSYCHOLOGICAL SERVICES INC
Entity Type:Organization
Organization Name:ROANOKE PSYCHOLOGICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:646-942-6852
Mailing Address - Street 1:71 SOUTH ORANGE AVE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079
Mailing Address - Country:US
Mailing Address - Phone:646-942-6852
Mailing Address - Fax:718-761-3094
Practice Address - Street 1:71 SOUTH ORANGE AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079
Practice Address - Country:US
Practice Address - Phone:646-942-6852
Practice Address - Fax:718-761-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3177103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7218907Medicaid
NJ689171Medicare PIN