Provider Demographics
NPI:1154747251
Name:ROARK, LINDA K
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:K
Last Name:ROARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27880 HACKBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-0561
Mailing Address - Country:US
Mailing Address - Phone:660-826-0244
Mailing Address - Fax:
Practice Address - Street 1:219 W 24TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-8303
Practice Address - Country:US
Practice Address - Phone:660-826-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCC1-0207-0413320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO852752203Medicaid