Provider Demographics
NPI:1265003776
Name:ROACH, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E STAN SCHLUETER LOOP
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5481
Mailing Address - Country:US
Mailing Address - Phone:727-278-2479
Mailing Address - Fax:
Practice Address - Street 1:1200 E STAN SCHLUETER LOOP
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5481
Practice Address - Country:US
Practice Address - Phone:727-278-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst