Provider Demographics
NPI:1922703552
Name:ROACH, CAMILLE LORRAINE
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:LORRAINE
Last Name:ROACH
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 1:107 LEO RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-2630
Mailing Address - Country:US
Mailing Address - Phone:475-414-3240
Mailing Address - Fax:
Practice Address - Street 1:367 PINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-1930
Practice Address - Country:US
Practice Address - Phone:413-867-1027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care