Healthcare Provider Details

I. General information

NPI: 1265437693
Provider Name (Legal Business Name): ALBERT ROGER GRIFFITH EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 ACADEMY ST STE 908
NEWARK NJ
07102-2928
US

IV. Provider business mailing address

270 EVERETT PL
ENGLEWOOD NJ
07631-1660
US

V. Phone/Fax

Practice location:
  • Phone: 973-624-4315
  • Fax: 973-624-0012
Mailing address:
  • Phone: 291-568-3467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35S100149000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: