Basic Information
| Provider Information | |||||||||
| NPI: | 1245401785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW-S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROACH | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW-S | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 LANE ST | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403558606 | ||||||||
| FaxNumber: | 7403531662 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 SPRING VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257049300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044296755 | ||||||||
| FaxNumber: | 3044297562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S-0500643 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | I1101573 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.