Provider Demographics
NPI:1558862979
Name:ROACHE, SUSAN LEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:ROACHE
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 1:197 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1288
Mailing Address - Country:US
Mailing Address - Phone:231-582-6365
Mailing Address - Fax:231-582-3738
Practice Address - Street 1:197 STATE ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1288
Practice Address - Country:US
Practice Address - Phone:213-582-6365
Practice Address - Fax:231-582-3738
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist