Provider Demographics
NPI:1912119165
Name:ROACH, DEANN LYNN (MS PT)
Entity Type:Individual
Prefix:MRS
First Name:DEANN
Middle Name:LYNN
Last Name:ROACH
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAGRUE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120
Mailing Address - Country:US
Mailing Address - Phone:501-779-1286
Mailing Address - Fax:
Practice Address - Street 1:111 LAGRUE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120
Practice Address - Country:US
Practice Address - Phone:501-779-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR14672251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T318OtherBLUE CROSS BLUE SHIELD