Provider Demographics
NPI:1992389548
Name:ROACH, KENNETH PHILLIP (MA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PHILLIP
Last Name:ROACH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 LANGHORNE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1121
Mailing Address - Country:US
Mailing Address - Phone:434-948-4831
Mailing Address - Fax:
Practice Address - Street 1:2215 LANGHORNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1121
Practice Address - Country:US
Practice Address - Phone:434-948-4831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010427101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional