Healthcare Provider Details

I. General information

NPI: 1952381006
Provider Name (Legal Business Name): SEAN MICHAEL ROACH PHD, PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 SW VETERANS WAY STE 1
REDMOND OR
97756-6408
US

IV. Provider business mailing address

494 SW VETERANS WAY STE 1
REDMOND OR
97756-6408
US

V. Phone/Fax

Practice location:
  • Phone: 719-373-5708
  • Fax:
Mailing address:
  • Phone: 719-373-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number04555
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: