Provider Demographics
NPI:1275597957
Name:ROA, MARK L (MA, LP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:ROA
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:2545 CHICAGO AVE
Practice Address - Street 2:SUITE 701
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4522
Practice Address - Country:US
Practice Address - Phone:612-863-5327
Practice Address - Fax:612-863-2596
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3689103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist