Healthcare Provider Details

I. General information

NPI: 1114401742
Provider Name (Legal Business Name): CAROLINE YAJAIRA ROACH LCADC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 ENGLE ST
ENGLEWOOD NJ
07631-2936
US

IV. Provider business mailing address

15 ENGLE STREET 15 ENGLE STREET
ENGLEWOOD NJ
07631
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-1224
  • Fax:
Mailing address:
  • Phone: 201-894-1224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00192700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00606900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: