Provider Demographics
NPI:1467934844
Name:ROARK, AMY ANNE DARCY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANNE DARCY
Last Name:ROARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DARCY
Other - Middle Name:
Other - Last Name:ROARK ROBINSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:53065 AVENIDA OBREGON
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3440
Mailing Address - Country:US
Mailing Address - Phone:714-907-7783
Mailing Address - Fax:
Practice Address - Street 1:9333 BASELINE RD STE 290
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1300
Practice Address - Country:US
Practice Address - Phone:909-755-5220
Practice Address - Fax:951-905-1617
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA8046976OtherCA DRIVERS LICENSE