Provider Demographics
NPI:1285705541
Name:ROACH, CAROL O (LICSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:O
Last Name:ROACH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:ROACH
Other - Last Name:FEINBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:72 ENGLEWOOD AVE
Mailing Address - Street 2:1
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7722
Mailing Address - Country:US
Mailing Address - Phone:617-277-8113
Mailing Address - Fax:
Practice Address - Street 1:37 BELMONT ST
Practice Address - Street 2:SOUTH BAY MENTAL HEALTH CENTER
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:508-588-5751
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1028873104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20679Medicare ID - Type Unspecified