Provider Demographics
NPI:1689731952
Name:ROCHE, REBECCA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:ROCHE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-3018
Mailing Address - Country:US
Mailing Address - Phone:716-773-6231
Mailing Address - Fax:
Practice Address - Street 1:712 MAIN ST
Practice Address - Street 2:SUITE L-2
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1720
Practice Address - Country:US
Practice Address - Phone:716-854-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR042611-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01910181Medicaid
NY000525440001OtherPROVIDER NUM
NY000525440001OtherPROVIDER NUM