Healthcare Provider Details

I. General information

NPI: 1447401195
Provider Name (Legal Business Name): IVAN MARIE ROQUE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 7TH ST NW
ALBUQUERQUE NM
87102-1244
US

IV. Provider business mailing address

1318 7TH ST NW
ALBUQUERQUE NM
87102-1244
US

V. Phone/Fax

Practice location:
  • Phone: 505-435-0074
  • Fax:
Mailing address:
  • Phone: 505-435-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09696
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: