Provider Demographics
NPI:1295941953
Name:ROACH, LAURIE DIANE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:DIANE
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 W PALM AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5770
Mailing Address - Country:US
Mailing Address - Phone:909-798-6164
Mailing Address - Fax:
Practice Address - Street 1:34324 YUCAIPA BLVD STE B-D
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2496
Practice Address - Country:US
Practice Address - Phone:909-790-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical