Healthcare Provider Details

I. General information

NPI: 1285299941
Provider Name (Legal Business Name): VANESSA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 E ORANGE GROVE BLVD STE 140
PASADENA CA
91104-5235
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 626-765-6010
  • Fax:
Mailing address:
  • Phone: 323-543-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: