Provider Demographics
NPI:1700424876
Name:ROACH, JOVAN ANDREW
Entity type:Individual
Prefix:
First Name:JOVAN
Middle Name:ANDREW
Last Name:ROACH
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 1:1205 SOPHIE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5948
Mailing Address - Country:US
Mailing Address - Phone:407-417-1869
Mailing Address - Fax:
Practice Address - Street 1:2301 MAITLAND CENTER PKWY
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4128
Practice Address - Country:US
Practice Address - Phone:407-574-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR200-421-95-335-1OtherDRIVERS LICENCE