Provider Demographics
NPI:1407415367
Name:ROACH, TIMOTHY MICHAEL (LMT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:ROACH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 MAIN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-2861
Mailing Address - Country:US
Mailing Address - Phone:631-456-3659
Mailing Address - Fax:
Practice Address - Street 1:544 MAIN ST APT 4
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-2861
Practice Address - Country:US
Practice Address - Phone:631-456-3659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025347225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist