Provider Demographics
NPI:1770663478
Name:ROACHE, DERICK DANVIL (RN LCSW PSYD)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:DANVIL
Last Name:ROACHE
Suffix:
Gender:M
Credentials:RN LCSW PSYD
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Mailing Address - Street 1:200 AVENUE F NORTH EAST
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881
Mailing Address - Country:US
Mailing Address - Phone:863-293-1121
Mailing Address - Fax:863-291-6084
Practice Address - Street 1:1201 FIRST STREET SOUTH
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-297-1702
Practice Address - Fax:863-291-6084
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLRN9178432163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health