Provider Demographics
NPI:1851806640
Name:ROACH, MERDITH DALE JR (LPC)
Entity Type:Individual
Prefix:
First Name:MERDITH
Middle Name:DALE
Last Name:ROACH
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8585 SIENNA SPRINGS BLVD APT 926
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-7205
Mailing Address - Country:US
Mailing Address - Phone:979-583-6627
Mailing Address - Fax:
Practice Address - Street 1:12234 SHADOW CREEK PKWY STE 4104
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7333
Practice Address - Country:US
Practice Address - Phone:713-429-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-03
Last Update Date:2017-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health