Basic Information
| Provider Information | |||||||||
| NPI: | 1063603546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | ANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 HAVEN AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | 9095572146 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 HAVEN AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | 9095572146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 175T00000X | Y |
No ID Information.