Provider Demographics
NPI:1104029321
Name:ROACH, KENDALL L (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:L
Last Name:ROACH
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:L
Other - Last Name:GRAYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E BRADFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4264
Mailing Address - Country:US
Mailing Address - Phone:417-761-5000
Mailing Address - Fax:417-761-5065
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:417-761-5065
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006026894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490117009Medicaid
11871325OtherCAQH