Provider Demographics
NPI:1114949351
Name:ROACH, JEFFREY PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
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 1:884 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-8169
Mailing Address - Country:US
Mailing Address - Phone:716-836-9460
Mailing Address - Fax:
Practice Address - Street 1:884 BRIGHTON RD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-8169
Practice Address - Country:US
Practice Address - Phone:716-836-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical