Provider Demographics
NPI:1821170663
Name:ROACH, RENEE R (LMHC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:R
Last Name:ROACH
Suffix:
Gender:F
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12031 172ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2622
Mailing Address - Country:US
Mailing Address - Phone:718-712-0036
Mailing Address - Fax:
Practice Address - Street 1:12031 172ND ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2622
Practice Address - Country:US
Practice Address - Phone:718-712-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP54287101YM0800X
NY004399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health