Provider Demographics
NPI:1689068181
Name:ROACH, MOLLY ELIZABETH (BCBA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:ROACH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11037 WARNER AVE
Mailing Address - Street 2:#339
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4007
Mailing Address - Country:US
Mailing Address - Phone:800-273-4292
Mailing Address - Fax:949-253-4627
Practice Address - Street 1:1700 NW 167TH PL STE 240
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4872
Practice Address - Country:US
Practice Address - Phone:855-423-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1-14-16890103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst