Provider Demographics
NPI:1538102421
Name:ROACH, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
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 1:2162 NE 154TH ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-6418
Mailing Address - Country:US
Mailing Address - Phone:904-964-4464
Mailing Address - Fax:
Practice Address - Street 1:417 W CALL ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3115
Practice Address - Country:US
Practice Address - Phone:904-964-4464
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist