Provider Demographics
NPI:1598163438
Name:ROACH, GLENDA GAYLE (LMSW, T-LAC)
Entity Type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:GAYLE
Last Name:ROACH
Suffix:
Gender:F
Credentials:LMSW, T-LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-3042
Mailing Address - Country:US
Mailing Address - Phone:785-843-9262
Mailing Address - Fax:785-843-8264
Practice Address - Street 1:3015 W 31ST ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-3042
Practice Address - Country:US
Practice Address - Phone:785-843-9262
Practice Address - Fax:785-843-9262
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW 9424101YA0400X
KST-LAC 1191101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)