Provider Demographics
NPI:1659345098
Name:ROACH, MARIE THERESA (PT)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:THERESA
Last Name:ROACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 12 85TH AVE
Mailing Address - Street 2:APT 5D
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3243
Mailing Address - Country:US
Mailing Address - Phone:718-847-2026
Mailing Address - Fax:
Practice Address - Street 1:340 E 24TH ST
Practice Address - Street 2:5TH FLOOR ICD REHABILITATION CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4019
Practice Address - Country:US
Practice Address - Phone:212-585-6214
Practice Address - Fax:212-585-6209
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0059791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist