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
State | License ID | Taxonomies |
---|---|---|
MN | LP5089 | 103TC0700X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 680002719 | Medicare PIN |