Provider Demographics
NPI:1518901735
Name:ROCHE, JOHN A
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ROCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2443 SAGVARO LANE
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083
Mailing Address - Country:US
Mailing Address - Phone:704-932-9384
Mailing Address - Fax:
Practice Address - Street 1:1309 SOUTH CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083
Practice Address - Country:US
Practice Address - Phone:704-933-3212
Practice Address - Fax:704-933-3221
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0034891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2342249OtherGROUP MEDICARE