Provider Demographics
NPI:1396786075
Name:ROACH, ANDREW (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 N RICHARDSON PLACE DR
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-3252
Mailing Address - Country:US
Mailing Address - Phone:501-860-1483
Mailing Address - Fax:
Practice Address - Street 1:11501 HURON LN
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1846
Practice Address - Country:US
Practice Address - Phone:501-860-1483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1225-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T467Medicare PIN