Healthcare Provider Details

I. General information

NPI: 1770867814
Provider Name (Legal Business Name): LEE EDWARD ROACH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5295 MILFORD DR
ZANESVILLE OH
43701-9649
US

IV. Provider business mailing address

25700 SCIENCE PARK DRIVE. SUITE 200 LANDMARK CENTRE.
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 740-452-9624
  • Fax:
Mailing address:
  • Phone: 216-831-1040
  • Fax: 216-831-2667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1913
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: