Provider Demographics
NPI:1982090569
Name:DELOACH, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:DELOACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-3703
Mailing Address - Country:US
Mailing Address - Phone:816-587-4100
Mailing Address - Fax:
Practice Address - Street 1:2020 S M-291 HWY
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1043
Practice Address - Country:US
Practice Address - Phone:816-461-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014044592101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health