Provider Demographics
NPI:1619684198
Name:ROQUE, THERESE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:ROQUE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 HOVENKAMP DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-2859
Mailing Address - Country:US
Mailing Address - Phone:972-977-8053
Mailing Address - Fax:
Practice Address - Street 1:9400 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5027
Practice Address - Country:US
Practice Address - Phone:972-581-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19698235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120085901Medicaid