Provider Demographics
NPI:1073227641
Name:LA ROCHE, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:LA ROCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BI COUNTY BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3988
Mailing Address - Country:US
Mailing Address - Phone:718-264-1640
Mailing Address - Fax:
Practice Address - Street 1:500 BI COUNTY BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3988
Practice Address - Country:US
Practice Address - Phone:718-264-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician