Provider Demographics
NPI: | 1649577396 |
---|---|
Name: | ROACH, ABBEY ROSE (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ABBEY |
Middle Name: | ROSE |
Last Name: | ROACH |
Suffix: | |
Gender: | F |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 100 E LIBERTY ST STE 800 |
Mailing Address - Street 2: | |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40202-1428 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 502-582-7484 |
Mailing Address - Fax: | 502-582-7646 |
Practice Address - Street 1: | 220 ABRAHAM FLEXNER WAY |
Practice Address - Street 2: | FRAZIER REHAB INSTITUTE-6TH FLOOR PSYCHOLOGY DPT. |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40202-3826 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-582-7484 |
Practice Address - Fax: | 502-582-7646 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-02-15 |
Last Update Date: | 2018-04-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 129461 | 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 7100162660 | Medicaid | |
IN | 201351950 (KOHMG) | Medicaid | |
KY | P00939731 | Medicare PIN | |
IN | 201351950 (KOHMG) | Medicaid |