Provider Demographics
NPI:1215955463
Name:ROCHE, THERESA A (MSW,LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:ROCHE
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:A
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW,LCSW
Mailing Address - Street 1:763 RIVER GLEN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-9647
Mailing Address - Country:US
Mailing Address - Phone:314-650-7768
Mailing Address - Fax:
Practice Address - Street 1:763 RIVER GLEN DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-9647
Practice Address - Country:US
Practice Address - Phone:636-244-1917
Practice Address - Fax:636-244-1917
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040087371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497324103Medicaid