Healthcare Provider Details

I. General information

NPI: 1285771824
Provider Name (Legal Business Name): ROBERTA ROACH M.A., C.A.D.C I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 82ND DR
GLADSTONE OR
97027-1803
US

IV. Provider business mailing address

880 82ND DR
GLADSTONE OR
97027-1803
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-5515
  • Fax: 503-659-1994
Mailing address:
  • Phone: 503-659-5515
  • Fax: 503-659-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: