Healthcare Provider Details

I. General information

NPI: 1104536663
Provider Name (Legal Business Name): ALEXANDRA ROQUE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2022
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MOUNTS CORNER DR
FREEHOLD NJ
07728-2547
US

IV. Provider business mailing address

1455 BROAD ST STE 250
BLOOMFIELD NJ
07003-3066
US

V. Phone/Fax

Practice location:
  • Phone: 732-538-8561
  • Fax:
Mailing address:
  • Phone: 877-532-7837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00334400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: