MEDICARE: MR. JAMES CLARK ROACH L.M.F.T

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	40674	CA

General Provider Information

NPI Number	:	1417089061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES CLARK ROACH L.M.F.T

Provider Business Mailing Address
First Line	:	11704 WILSHIRE BLVD STE 250
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1504
Country	:	US
Telephone Number	:	310-488-1274
Fax Number	:

Provider Business Practice Location Address
First Line	:	11704 WILSHIRE BLVD STE 250
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1504
Country	:	US
Telephone Number	:	310-488-1274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/21/2022

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