Provider Demographics
NPI:1154529113
Name:ROACH, KATRINA ELISABETH (PTA)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:ELISABETH
Last Name:ROACH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:ELISABETH
Other - Last Name:SENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5148 TRUEMPER WAY APT 9
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3219
Mailing Address - Country:US
Mailing Address - Phone:260-485-0286
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003339A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant