Healthcare Provider Details

I. General information

NPI: 1821033929
Provider Name (Legal Business Name): LENORE J ROACH LISW,LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 01/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GRANT AVE
LAKE KATRINE NY
12449-5340
US

IV. Provider business mailing address

55 DEPEW RD APT 4
HIGH FALLS NY
12440-5618
US

V. Phone/Fax

Practice location:
  • Phone: 845-336-3500
  • Fax:
Mailing address:
  • Phone: 845-687-0735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberRO43601-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: