Provider Demographics
NPI:1609524370
Name:ROCHE, MICHAELA RUTH
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:RUTH
Last Name:ROCHE
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 1:6100 MASON CREEK CIR UNIT 309
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7916
Mailing Address - Country:US
Mailing Address - Phone:860-212-5933
Mailing Address - Fax:
Practice Address - Street 1:7940 WILLIAMS POND LN STE 250
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8412
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17443101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty