Basic Information
| Provider Information | |||||||||
| NPI: | 1447401195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROQUE | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1637 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423021637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706896500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 BROADWAY BLVD NE STE 500 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052680701 | ||||||||
| FaxNumber: | 2706896677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C-09696 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.