Provider Demographics
NPI:1750478483
Name:HEGARTY ROACH, MIA CHRISTINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:CHRISTINE
Last Name:HEGARTY ROACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 S PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:IA
Mailing Address - Zip Code:50511-3649
Mailing Address - Country:US
Mailing Address - Phone:515-295-7714
Mailing Address - Fax:515-295-4505
Practice Address - Street 1:1519 S PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:IA
Practice Address - Zip Code:50511-3649
Practice Address - Country:US
Practice Address - Phone:515-295-7714
Practice Address - Fax:515-295-4505
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1035103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71759OtherWELLMARK
P93631Medicare UPIN