Provider Demographics
NPI:1205114030
Name:ROARK, THOMAS M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:ROARK
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7503 N 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-5416
Mailing Address - Country:US
Mailing Address - Phone:402-616-4192
Mailing Address - Fax:402-932-1888
Practice Address - Street 1:3110 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-2604
Practice Address - Country:US
Practice Address - Phone:402-203-6112
Practice Address - Fax:402-932-1888
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE848235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist