Provider Demographics
NPI:1154702207
Name:ROESCH, RACHEL LYSZCZYK (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:LYSZCZYK
Last Name:ROESCH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:LYSZCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:783 STEBBINS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4217
Mailing Address - Country:US
Mailing Address - Phone:704-785-1036
Mailing Address - Fax:252-525-4848
Practice Address - Street 1:783 STEBBINS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4217
Practice Address - Country:US
Practice Address - Phone:704-785-1036
Practice Address - Fax:252-525-4848
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA2000Medicaid