Healthcare Provider Details

I. General information

NPI: 1508857699
Provider Name (Legal Business Name): ROGER A. KALTHOFF, PH.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 W 4TH ST
WINSTON SALEM NC
27101-2564
US

IV. Provider business mailing address

711 S MARSHALL ST UNIT C
WINSTON SALEM NC
27101-5849
US

V. Phone/Fax

Practice location:
  • Phone: 336-577-8041
  • Fax:
Mailing address:
  • Phone: 336-577-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2749
License Number StateNC

VIII. Authorized Official

Name: ROGER ALAN KALTHOFF
Title or Position: OWNER/PRESIDENT
Credential: PH.D.
Phone: 336-577-8041