Provider Demographics
NPI:1235433376
Name:ROACH, MARY JANE (SLP)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-2216
Mailing Address - Country:US
Mailing Address - Phone:518-577-1671
Mailing Address - Fax:
Practice Address - Street 1:330 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-2216
Practice Address - Country:US
Practice Address - Phone:518-577-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003216-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist