Provider Demographics
NPI:1033724497
Name:ROACH, AI O (BCBA)
Entity type:Individual
Prefix:
First Name:AI
Middle Name:O
Last Name:ROACH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 S J ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-5038
Mailing Address - Country:US
Mailing Address - Phone:206-380-7066
Mailing Address - Fax:
Practice Address - Street 1:BOX 357921 IHCD CD-205
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-3112
Practice Address - Country:US
Practice Address - Phone:206-543-8379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61600090103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst