Provider Demographics
NPI:1780318220
Name:ROACH, TERESA L
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8725 E HOBART ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-4107
Mailing Address - Country:US
Mailing Address - Phone:480-937-6766
Mailing Address - Fax:
Practice Address - Street 1:1423 S HIGLEY RD STE 103
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3449
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:641-902-6480
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)