Provider Demographics
NPI:1952440794
Name:ROACHE, LAURA (MED)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ROACHE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 N CAMAC ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3521
Mailing Address - Country:US
Mailing Address - Phone:215-763-3680
Mailing Address - Fax:
Practice Address - Street 1:1632 W DIAMOND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-2313
Practice Address - Country:US
Practice Address - Phone:215-763-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA01974330101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor