Provider Demographics
NPI:1952381006
Name:ROACH, SEAN MICHAEL (PHD, PT, DPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:MICHAEL
Last Name:ROACH
Suffix:
Gender:M
Credentials:PHD, PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 SW VETERANS WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-6408
Mailing Address - Country:US
Mailing Address - Phone:719-373-5708
Mailing Address - Fax:
Practice Address - Street 1:494 SW VETERANS WAY STE 1
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-6408
Practice Address - Country:US
Practice Address - Phone:719-373-5708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04555225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8632629771OtherSTATE OF OREGON