Provider Demographics
NPI:1659760387
Name:ROACH, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11858 N 900 W
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960-7801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11858 N 900 W
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-7801
Practice Address - Country:US
Practice Address - Phone:574-581-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005619A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist