Provider Demographics
NPI:1861157323
Name:ROACH, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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 1:50 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-5001
Mailing Address - Country:US
Mailing Address - Phone:203-907-9462
Mailing Address - Fax:
Practice Address - Street 1:175 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4357
Practice Address - Country:US
Practice Address - Phone:203-789-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62.002023225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant