Provider Demographics
NPI:1750161097
Name:ROACHE, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:ROACHE
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 1:1388 DERMOND RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-4904
Mailing Address - Country:US
Mailing Address - Phone:484-680-0828
Mailing Address - Fax:
Practice Address - Street 1:1388 DERMOND RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-4904
Practice Address - Country:US
Practice Address - Phone:484-680-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE247770103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool