Provider Demographics
NPI:1669191367
Name:ROESCH, JOAN LOUISE
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:LOUISE
Last Name:ROESCH
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 1:369 YETMAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1821
Mailing Address - Country:US
Mailing Address - Phone:718-689-3715
Mailing Address - Fax:
Practice Address - Street 1:460 BRIELLE AVE BLDG H
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6427
Practice Address - Country:US
Practice Address - Phone:718-816-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37652101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)