Basic Information
| Provider Information | |||||||||
| NPI: | 1215211610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICAL THERAPIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OVERBEE | ||||||||
| OtherFirstName: | CASEY | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
| FaxNumber: | 6184410482 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 MAYSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403539767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594994351 | ||||||||
| FaxNumber: | 8594994321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 005903 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 005903 | 01 | KY | KENTUCKY BOARD OF PHYSICAL THERAPY | OTHER |