Provider Demographics
NPI:1356824957
Name:ROACH, LAURA E (LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:ROACH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:POLLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5533
Mailing Address - Fax:262-293-9737
Practice Address - Street 1:4351 W COLLEGE AVE STE 410
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3928
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:526-234-5562
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10015-125101YP2500X
WI4101-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081602Medicaid