Provider Demographics
NPI:1174524656
Name:ROESCH, ROBERTA JEAN (LISW)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:JEAN
Last Name:ROESCH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:L-3549
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-383-7910
Practice Address - Fax:740-375-8129
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0009456104100000X
OHI.0009456-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH129280Medicare PIN
OHSW25421Medicare ID - Type Unspecified