Provider Demographics
NPI:1619189628
Name:ROACH, KENNETH DAVID (LCMHC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:ROACH
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 LOCH LOMOND WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4974
Mailing Address - Country:US
Mailing Address - Phone:801-281-1078
Mailing Address - Fax:801-269-7565
Practice Address - Street 1:4190 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2674
Practice Address - Country:US
Practice Address - Phone:801-792-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4909154-6004101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health