Provider Demographics
NPI:1558052217
Name:ROACH, CHYVONNE ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CHYVONNE
Middle Name:ELIZABETH
Last Name:ROACH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 CLEARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-9133
Mailing Address - Country:US
Mailing Address - Phone:917-754-0010
Mailing Address - Fax:
Practice Address - Street 1:1504 RENAISSANCE DR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3895
Practice Address - Country:US
Practice Address - Phone:470-467-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008428225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist