Provider Demographics
NPI:1619048980
Name:ROARK, HEATHER JOY (PSY D, LP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:JOY
Last Name:ROARK
Suffix:
Gender:F
Credentials:PSY D, LP
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:JOY
Other - Last Name:STANAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-1188
Mailing Address - Country:US
Mailing Address - Phone:218-749-2881
Mailing Address - Fax:218-749-3806
Practice Address - Street 1:624 13TH ST S
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-3149
Practice Address - Country:US
Practice Address - Phone:218-749-2881
Practice Address - Fax:218-749-3806
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5089103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680002719Medicare PIN