Provider Demographics
NPI:1881742005
Name:ROACH, NORMAN WERNER (PHD)
Entity type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:WERNER
Last Name:ROACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 EL CAMINO REAL REAR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3602
Mailing Address - Country:US
Mailing Address - Phone:714-731-6644
Mailing Address - Fax:714-389-9329
Practice Address - Street 1:190 EL CAMINO REAL REAR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3602
Practice Address - Country:US
Practice Address - Phone:714-731-6644
Practice Address - Fax:714-389-9329
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6594103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP6594Medicare ID - Type UnspecifiedMEDICARE PROVIDER #