Provider Demographics
NPI:1942323191
Name:ROCHE, KATHLEEN MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:ROCHE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2969
Mailing Address - Country:US
Mailing Address - Phone:618-234-1455
Mailing Address - Fax:
Practice Address - Street 1:5003 N ILLINOIS ST
Practice Address - Street 2:SUITE 2
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3419
Practice Address - Country:US
Practice Address - Phone:618-234-1455
Practice Address - Fax:618-277-3475
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU74143Medicare UPIN
IL535130Medicare ID - Type Unspecified