Provider Demographics
NPI:1902983059
Name:ROACH, SUZANNE RENAE (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RENAE
Last Name:ROACH
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 ANNADALE CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9508
Mailing Address - Country:US
Mailing Address - Phone:870-931-9374
Mailing Address - Fax:
Practice Address - Street 1:4320 ANNADALE CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9508
Practice Address - Country:US
Practice Address - Phone:870-931-9374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X140OtherBLUE CROSS