Provider Demographics
NPI:1043265598
Name:ROACH, ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-1005
Mailing Address - Country:US
Mailing Address - Phone:585-442-9601
Mailing Address - Fax:585-442-9606
Practice Address - Street 1:1357 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1005
Practice Address - Country:US
Practice Address - Phone:585-442-9601
Practice Address - Fax:585-442-9606
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006084103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY100204FCOtherPREFERRED CARE PROVIDER #
NY0005103143OtherAETNA PROVIDER #
NY100204FCOtherPREFERRED CARE PROVIDER #