Provider Demographics
NPI:1558696393
Name:ROQUE, CHRISTOPHER MATIC (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MATIC
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 1:487 ST. MARKS AVENUE
Mailing Address - Street 2:APT 3LR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:925-768-5713
Mailing Address - Fax:
Practice Address - Street 1:1234 INDIANA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-3406
Practice Address - Country:US
Practice Address - Phone:415-282-9675
Practice Address - Fax:415-920-6877
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NY0856561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor