Provider Demographics
NPI:1992703615
Name:ROE, ALLAN (PHD)
Entity type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:
Last Name:ROE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 N 900 E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3536
Mailing Address - Country:US
Mailing Address - Phone:801-442-7620
Mailing Address - Fax:801-422-0165
Practice Address - Street 1:1190 N 900 E
Practice Address - Street 2:SUITE 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3536
Practice Address - Country:US
Practice Address - Phone:801-422-7620
Practice Address - Fax:801-422-0165
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107621-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000000129Medicare ID - Type Unspecified