Healthcare Provider Details

I. General information

NPI: 1083968200
Provider Name (Legal Business Name): ANTHONY ROACH PC-IT, SW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD STE 200
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

3900 W BROWN DEER RD STE 200
BROWN DEER WI
53209-1220
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax: 414-540-2171
Mailing address:
  • Phone: 414-540-2170
  • Fax: 414-540-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1281-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7196-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: