Provider Demographics
NPI:1033548300
Name:ROSE ROACH PSYCHOTHERAPY
Entity Type:Organization
Organization Name:ROSE ROACH PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-271-5487
Mailing Address - Street 1:600 E STRAWBRIDGE AVE
Mailing Address - Street 2:200
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 E STRAWBRIDGE AVE
Practice Address - Street 2:200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4796
Practice Address - Country:US
Practice Address - Phone:321-271-5487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW93621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty