Provider Demographics
NPI:1659587814
Name:ROAN, ELAINE (LISAC)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:ROAN
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2155
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2155
Mailing Address - Country:US
Mailing Address - Phone:928-283-3346
Mailing Address - Fax:928-283-3039
Practice Address - Street 1:160 NORTH MAIN STREET
Practice Address - Street 2:BUILDING 25
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-3046
Practice Address - Fax:928-283-3039
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11593101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)