Provider Demographics
NPI:1962740076
Name:ROACH, DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 MADISON ST STE 7
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3248
Mailing Address - Country:US
Mailing Address - Phone:516-334-1719
Mailing Address - Fax:
Practice Address - Street 1:309 MADISON ST STE 7
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3248
Practice Address - Country:US
Practice Address - Phone:516-334-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085916-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical