MEDICARE: DR. KENNETH DAVID ROACH LCMHC

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	101YM0800X	Mental Health Counselor	4909154-6004	UT
2	101YP2500X	Professional Counselor	4909154-6004	UT

General Provider Information

NPI Number	:	1619189628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH DAVID ROACH LCMHC

Provider Business Mailing Address
First Line	:	1131 LOCH LOMOND WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4974
Country	:	US
Telephone Number	:	801-281-1078
Fax Number	:	801-269-7565

Provider Business Practice Location Address
First Line	:	4190 S HIGHLAND DR STE 210
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2674
Country	:	US
Telephone Number	:	801-792-7028
Fax Number	:

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	10/10/2018

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