Healthcare Provider Details

I. General information

NPI: 1912435546
Provider Name (Legal Business Name): EVON ROQUEMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BUSINESS PARK DR
DENHAM SPRINGS LA
70726-7825
US

IV. Provider business mailing address

106 BUSINESS PARK DR
DENHAM SPRINGS LA
70726-7825
US

V. Phone/Fax

Practice location:
  • Phone: 888-417-5250
  • Fax: 225-341-8756
Mailing address:
  • Phone: 888-417-5250
  • Fax: 225-341-8756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: