Provider Demographics
NPI:1508297128
Name:ROACH, WHITNEY
Entity Type:Individual
Prefix:
First Name:WHITNEY
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 1:73 RUSSELBURG LN
Mailing Address - Street 2:
Mailing Address - City:CLOVERPORT
Mailing Address - State:KY
Mailing Address - Zip Code:40111-5248
Mailing Address - Country:US
Mailing Address - Phone:270-617-3185
Mailing Address - Fax:
Practice Address - Street 1:73 RUSSELBURG LN
Practice Address - Street 2:
Practice Address - City:CLOVERPORT
Practice Address - State:KY
Practice Address - Zip Code:40111-5248
Practice Address - Country:US
Practice Address - Phone:270-617-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist