MEDICARE: DR. ROGER KENNETH LIGHT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PSY9830	CA
2	103G00000X	Clinical Neuropsychologist	PSY819	HI

General Provider Information

NPI Number	:	1992924047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER KENNETH LIGHT PH.D.

Provider Business Mailing Address
First Line	:	509 N SEPULVEDA BLVD
Second Line	:	SUITE 204
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6746
Country	:	US
Telephone Number	:	310-374-1221
Fax Number	:	310-214-0648

Provider Business Practice Location Address
First Line	:	509 N SEPULVEDA BLVD
Second Line	:	SUITE 204
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-6746
Country	:	US
Telephone Number	:	310-374-1221
Fax Number	:	310-214-0648

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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