Provider Demographics
NPI:1447086111
Name:ROESCH, AMANDA LOIS (LMT)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:LOIS
Last Name:ROESCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 JOE NESTOR RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-8026
Mailing Address - Country:US
Mailing Address - Phone:505-250-3654
Mailing Address - Fax:
Practice Address - Street 1:1 LINNIE CT
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-9125
Practice Address - Country:US
Practice Address - Phone:505-250-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5951225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist