Provider Demographics
NPI:1760528160
Name:ROACH, SARAH E (PTA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:ROACH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WILLIS CT
Mailing Address - Street 2:
Mailing Address - City:NORTH FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1054
Mailing Address - Country:US
Mailing Address - Phone:920-926-1086
Mailing Address - Fax:
Practice Address - Street 1:3305 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9001
Practice Address - Country:US
Practice Address - Phone:920-735-9234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant