Provider Demographics
NPI:1649894445
Name:ROACH, LILY JEANNINE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:JEANNINE
Last Name:ROACH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 VOLNEY ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-3104
Mailing Address - Country:US
Mailing Address - Phone:315-695-1555
Mailing Address - Fax:
Practice Address - Street 1:116 VOLNEY ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-3104
Practice Address - Country:US
Practice Address - Phone:315-695-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist