Provider Demographics
NPI:1679511018
Name:ROQUE-DIAZ, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:ROQUE-DIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8930 FOURWINDS DR
Mailing Address - Street 2:STE 335
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78239-1970
Mailing Address - Country:US
Mailing Address - Phone:210-618-7249
Mailing Address - Fax:210-590-0355
Practice Address - Street 1:8930 FOURWINDS DR
Practice Address - Street 2:STE 335
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78239-1970
Practice Address - Country:US
Practice Address - Phone:210-618-7249
Practice Address - Fax:210-590-0355
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX049061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040251301Medicaid
TX82296WMedicare ID - Type UnspecifiedMEDICARE NO
TX040251301Medicaid