Provider Demographics
NPI:1386650380
Name:ROACH, CAROL NANNETTE (PHD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:NANNETTE
Last Name:ROACH
Suffix:
Gender:F
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:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-1001
Mailing Address - Country:US
Mailing Address - Phone:641-676-3999
Mailing Address - Fax:866-371-0412
Practice Address - Street 1:201 HIGH AVE E
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-2838
Practice Address - Country:US
Practice Address - Phone:641-676-3999
Practice Address - Fax:866-371-0412
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAI00981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI00981OtherIOWA