Provider Demographics
NPI:1598098006
Name:ROQUEMORE, AARON (EDD)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:
Last Name:ROQUEMORE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-2704
Mailing Address - Country:US
Mailing Address - Phone:470-204-7956
Mailing Address - Fax:866-217-7073
Practice Address - Street 1:210 S 13TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:470-204-7956
Practice Address - Fax:866-217-7073
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000524101YP2500X
GAMFT000232106H00000X
GA000232106H00000X
GALPC000524101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA889079225AMedicaid