Provider Demographics
NPI:1619210069
Name:ROCHE, MICHAEL (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROCHE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SYAMORE AVE
Mailing Address - Street 2:SUITE 39
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716
Mailing Address - Country:US
Mailing Address - Phone:631-758-8290
Mailing Address - Fax:
Practice Address - Street 1:3771 NESCONSET HWY STE 214
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1154
Practice Address - Country:US
Practice Address - Phone:347-450-1136
Practice Address - Fax:347-294-4131
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1068106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty