Provider Demographics
NPI:1922558808
Name:ROE, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:ROE
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 1:8928 VOLUNTEER LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8928 VOLUNTEER LN
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3238
Practice Address - Country:US
Practice Address - Phone:916-368-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW73363101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSSN