Provider Demographics
NPI:1043390255
Name:ROACH, BRETT REAGAN (LPC, LMFT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:REAGAN
Last Name:ROACH
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 PLEASANT HILL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3406
Mailing Address - Country:US
Mailing Address - Phone:540-904-6488
Mailing Address - Fax:540-904-6482
Practice Address - Street 1:4800 PLEASANT HILL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3406
Practice Address - Country:US
Practice Address - Phone:540-989-1383
Practice Address - Fax:540-989-8092
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001950101YP2500X
VA0717000107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA038449OtherANTHEM/BCBS