Provider Demographics
NPI:1912906058
Name:PEDERSON, ROGER A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S MAIN ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-3102
Mailing Address - Country:US
Mailing Address - Phone:574-523-3347
Mailing Address - Fax:574-296-7560
Practice Address - Street 1:307 S MAIN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3102
Practice Address - Country:US
Practice Address - Phone:574-523-3347
Practice Address - Fax:574-296-7560
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001185A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
145540FMedicare ID - Type Unspecified
P04651Medicare UPIN