Individual
SHAWANA ROACH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
10424 WALTON LAKE RD, DISPUTANTA, VA 23842-4703
(757) 477-0424
Mailing address
10424 WALTON LAKE RD, DISPUTANTA, VA 23842-4703
(757) 477-0424
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
2452--01-001
VA
Other
Enumeration date
05/22/2018
Last updated
05/22/2018
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