Provider Demographics
NPI:1972650273
Name:ROACH, LARRY (LMHC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S DILLARD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3523
Mailing Address - Country:US
Mailing Address - Phone:407-716-7083
Mailing Address - Fax:
Practice Address - Street 1:204 S DILLARD ST
Practice Address - Street 2:SUITE C
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3523
Practice Address - Country:US
Practice Address - Phone:407-716-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6968101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health