Provider Demographics
NPI:1295961910
Name:ROACH, KIMBERLY A (DPT)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:ROACH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 ROACH RD
Mailing Address - Street 2:
Mailing Address - City:CHOUDRANT
Mailing Address - State:LA
Mailing Address - Zip Code:71227-3630
Mailing Address - Country:US
Mailing Address - Phone:318-224-9081
Mailing Address - Fax:318-224-9083
Practice Address - Street 1:1316 EAST KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-224-9081
Practice Address - Fax:318-224-9083
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1884600Medicaid