Provider Demographics
NPI:1720112386
Name:ROEDER, ELAINE JUDITH (LICSW)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:JUDITH
Last Name:ROEDER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CONSTITUTION RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6654
Mailing Address - Country:US
Mailing Address - Phone:781-862-3471
Mailing Address - Fax:
Practice Address - Street 1:111 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4141
Practice Address - Country:US
Practice Address - Phone:978-369-1113
Practice Address - Fax:978-369-0908
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1117921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP10320OtherBCBS
MA279202OtherTRICARE
MAP10320OtherBCBS