Provider Demographics
NPI:1588034383
Name:ROACH, WADE (COTA/L)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 N MAIN ST
Mailing Address - Street 2:5085876566
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1668
Mailing Address - Country:US
Mailing Address - Phone:508-587-6566
Mailing Address - Fax:
Practice Address - Street 1:888 N MAIN ST
Practice Address - Street 2:5085876566
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1668
Practice Address - Country:US
Practice Address - Phone:508-587-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3996224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant