Provider Demographics
NPI:1073053963
Name:ROACH, CRYSTAL (OT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:MORPHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:874 HALLEY RD.
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:874 HALLEY RD.
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662
Practice Address - Country:US
Practice Address - Phone:559-741-6390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006644225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003186278AMedicaid
GA003186278CMedicaid