Healthcare Provider Details

I. General information

NPI: 1417286071
Provider Name (Legal Business Name): DEANNE ROCHE NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12110 CLAYTON RD
SAINT LOUIS MO
63131-2516
US

IV. Provider business mailing address

5114 SUSON WAY CT
SAINT LOUIS MO
63128-4531
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number39087
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: