Basic Information
Provider Information
NPI: 1033558606
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROACH
FirstName: CHRISTINA
MiddleName: M
NamePrefix: MS.
NameSuffix:  
Credential: MA, LMHC, NCC, DCC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4207 W GRANADA ST
Address2:  
City: TAMPA
State: FL
PostalCode: 336296616
CountryCode: US
TelephoneNumber: 8137848952
FaxNumber: 8138395333
Practice Location
Address1: 425 S ORLEANS AVE
Address2:  
City: TAMPA
State: FL
PostalCode: 336062139
CountryCode: US
TelephoneNumber: 8137848952
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/17/2013
LastUpdateDate: 06/17/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800XMH 11532FLY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


Home