Healthcare Provider Details

I. General information

NPI: 1295235836
Provider Name (Legal Business Name): THERESA DEC ROACH MS, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR
SANTA FE NM
87507-4929
US

IV. Provider business mailing address

3201 ZAFARANO DR STE C #232
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 602-316-6058
  • Fax:
Mailing address:
  • Phone: 602-316-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: