Provider Demographics
NPI:1518364595
Name:ROACH, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4762 ROLLRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-8689
Mailing Address - Country:US
Mailing Address - Phone:269-270-7955
Mailing Address - Fax:
Practice Address - Street 1:1613 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5748
Practice Address - Country:US
Practice Address - Phone:269-925-0585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010932701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical