Provider Demographics
NPI:1770257339
Name:ROA, CARMEN LYDIA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LYDIA
Last Name:ROA
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 1:5121 STOCKDALE HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-2664
Mailing Address - Country:US
Mailing Address - Phone:661-473-1500
Mailing Address - Fax:661-735-8559
Practice Address - Street 1:5121 STOCKDALE HWY STE 200
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-2664
Practice Address - Country:US
Practice Address - Phone:661-473-1500
Practice Address - Fax:661-735-8559
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X, 175T00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer Specialist