Provider Demographics
NPI:1326662859
Name:ROACH, COURTNEY LYNN
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:ROACH
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 1:353 TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3625
Mailing Address - Country:US
Mailing Address - Phone:207-829-4825
Mailing Address - Fax:207-829-2254
Practice Address - Street 1:353 TUTTLE RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-3625
Practice Address - Country:US
Practice Address - Phone:207-829-4825
Practice Address - Fax:207-829-2254
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT3705225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist