Provider Demographics
NPI:1477868461
Name:ROACH, ANDREA (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2639 S MOORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227
Mailing Address - Country:US
Mailing Address - Phone:720-542-8021
Mailing Address - Fax:
Practice Address - Street 1:2639 S MOORE DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-6522
Practice Address - Country:US
Practice Address - Phone:720-542-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist