Nicole Brook Roach, PTA, LMT

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

2018037409 Issued in MO

Practice address

1720 Vieth Dr
Jefferson City, MO 65109-2056

Phone

(573) 635-6139

NPI assigned

Dec 17, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1545004800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1545004800000",
    "number": "1275004210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2223 BUEHRLE DR",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651091926",
            "telephone_number": "573-462-0853"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1720 VIETH DR",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651092056",
            "telephone_number": "573-635-6139"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROACH",
        "first_name": "NICOLE",
        "middle_name": "BROOK",
        "credential": "PTA, LMT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-12-17",
        "last_updated": "2018-12-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "MO",
            "license": "2018037409",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapy Assistant in Jefferson City, MO
• Providers in Jefferson City, MO by specialty
• Physical Therapy Assistant in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.