Healthcare Provider Details

I. General information

NPI: 1720767569
Provider Name (Legal Business Name): MALAIKA ROACH CASAC ADV, CPRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17545 88TH AVE APT 2B
JAMAICA NY
11432-5703
US

IV. Provider business mailing address

17545 88TH AVE APT 2B
JAMAICA NY
11432-5703
US

V. Phone/Fax

Practice location:
  • Phone: 718-810-9218
  • Fax:
Mailing address:
  • Phone: 718-810-9218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number5383
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberEXEMPT
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number28450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: