Provider Demographics
NPI:1306324777
Name:ROACH, ANNE MARIE (MS, LPCC, LADC)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:MARIE
Last Name:ROACH
Suffix:
Gender:F
Credentials:MS, LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3770
Mailing Address - Country:US
Mailing Address - Phone:320-232-5402
Mailing Address - Fax:
Practice Address - Street 1:823 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3770
Practice Address - Country:US
Practice Address - Phone:320-232-5402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303339101YA0400X
MN01866101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)