Provider Demographics
NPI:1497420319
Name:ROACH, MASON
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 RENAN RD
Mailing Address - Street 2:
Mailing Address - City:HURT
Mailing Address - State:VA
Mailing Address - Zip Code:24563-2077
Mailing Address - Country:US
Mailing Address - Phone:434-841-7405
Mailing Address - Fax:
Practice Address - Street 1:39 BANK ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:VA
Practice Address - Zip Code:24531-1129
Practice Address - Country:US
Practice Address - Phone:434-432-2761
Practice Address - Fax:434-432-2893
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000684235Z00000X
VA2202010448235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist