Provider Demographics
NPI:1447401195
Name:ROQUE, IVAN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:MARIE
Last Name:ROQUE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1637
Mailing Address - Country:US
Mailing Address - Phone:270-689-6500
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE STE 500
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2367
Practice Address - Country:US
Practice Address - Phone:505-268-0701
Practice Address - Fax:270-689-6677
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-096961041C0700X
ORA2941104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM08032777Medicaid