Provider Demographics
NPI:1174884670
Name:ROACH, KIMBERLY JANE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JANE
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 N CLASSEN BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-4622
Mailing Address - Country:US
Mailing Address - Phone:918-724-1473
Mailing Address - Fax:
Practice Address - Street 1:12104 S 85TH EAST AVE
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-2703
Practice Address - Country:US
Practice Address - Phone:918-724-1473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional