Provider Demographics
NPI:1205347465
Name:ROACH, SHIRLEEN KAY (LAMFT)
Entity type:Individual
Prefix:
First Name:SHIRLEEN
Middle Name:KAY
Last Name:ROACH
Suffix:
Gender:F
Credentials:LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17305 MEADOW CREEK LANE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063
Mailing Address - Country:US
Mailing Address - Phone:763-444-4838
Mailing Address - Fax:
Practice Address - Street 1:17305 MEADOW CREEK LANE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:763-444-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3302101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health