1700199361 NPI number — MRS. DIANA MARIE ROACH LPC, CCMHC

Table of content: MRS. DIANA MARIE ROACH LPC, CCMHC (NPI 1700199361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700199361 NPI number — MRS. DIANA MARIE ROACH LPC, CCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROACH
Provider First Name:
DIANA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, CCMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FALZARANO
Provider Other First Name:
DIANA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700199361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 COBBLE HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07821-2321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
862-266-3217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 LIBERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07860-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
862-266-3217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  37PC00018200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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