Provider Demographics
NPI:1134216948
Name:DAFTER, ROGER E (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:E
Last Name:DAFTER
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 1:13111 SHERRY LANE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049
Mailing Address - Country:US
Mailing Address - Phone:310-597-9977
Mailing Address - Fax:
Practice Address - Street 1:2444 WILSHIRE BLVD STE 506
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5814
Practice Address - Country:US
Practice Address - Phone:310-597-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDCP 8184Medicare ID - Type Unspecified