Healthcare Provider Details

I. General information

NPI: 1558696393
Provider Name (Legal Business Name): CHRISTOPHER MATIC ROQUE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 INDIANA ST
SAN FRANCISCO CA
94107-3406
US

IV. Provider business mailing address

487 ST. MARKS AVENUE APT 3LR
BROOKLYN NY
11238
US

V. Phone/Fax

Practice location:
  • Phone: 415-282-9675
  • Fax: 415-920-6877
Mailing address:
  • Phone: 925-768-5713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085656
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: