Provider Demographics
NPI:1003369885
Name:ROQUEMORE, COURTNEY E
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:E
Last Name:ROQUEMORE
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 1:9262 HIGHWAY 120
Mailing Address - Street 2:
Mailing Address - City:ROBELINE
Mailing Address - State:LA
Mailing Address - Zip Code:71469-4302
Mailing Address - Country:US
Mailing Address - Phone:318-663-1882
Mailing Address - Fax:
Practice Address - Street 1:9262 HIGHWAY 120
Practice Address - Street 2:
Practice Address - City:ROBELINE
Practice Address - State:LA
Practice Address - Zip Code:71469
Practice Address - Country:US
Practice Address - Phone:318-663-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA929047191Medicaid
LA110648162Medicaid