Provider Demographics
NPI:1144681115
Name:ROACH, KATHERINE (LCSW)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:VENEGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:10750 4TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0979
Mailing Address - Country:US
Mailing Address - Phone:909-214-1378
Mailing Address - Fax:
Practice Address - Street 1:10750 4TH ST STE 150
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0979
Practice Address - Country:US
Practice Address - Phone:909-214-1378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW719031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical