Healthcare Provider Details

I. General information

NPI: 1316450265
Provider Name (Legal Business Name): PHILISIA ROQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 NE KANE DR APT 102
GRESHAM OR
97030-5968
US

IV. Provider business mailing address

8915 SW CENTER ST
TIGARD OR
97223-6307
US

V. Phone/Fax

Practice location:
  • Phone: 503-573-7182
  • Fax: 503-573-7182
Mailing address:
  • Phone: 503-726-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: