Provider Demographics
NPI:1912932294
Name:ROEDER, KEITH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:ROEDER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PLAZA MIDDLESEX
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:MIDDLESEX
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-347-9911
Mailing Address - Fax:860-347-8120
Practice Address - Street 1:300 PLAZA MIDDLESEX
Practice Address - Street 2:3RD FLOOR
Practice Address - City:MIDDLESEX
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-9911
Practice Address - Fax:860-347-8120
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1719103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
060001719CT01OtherBLUE CROSS
163070OtherVALUE OPTIONS
P664410OtherOXFORD
1037571OtherCIGNA
708160OtherMAGELLAN
157460OtherMHN
CT00414087800Medicaid
0567535OtherUHC
CT4257498OtherAETNA