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General NPI Number Information
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NPI Number | 1154340768
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Entity Type | Individual
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Provider Name | THEODUS MARQUES ROACH LCSW
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Gender | Male
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Dates
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Enumeration Date | 07/18/2006
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 210 POSTAGE WAY #1772
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City | INDIAN TRAIL
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State | NC
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Zip | 28079-9701
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Country | US
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Telephone | 980-338-5563
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Fax | 704-228-0260
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Provider Business Mailing Address
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Address Line | 1006 SEBASTIAN CT
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City | INDIAN TRAIL
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State | NC
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Zip | 28079-3688
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Country | US
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Telephone | 980-338-5563
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Fax | 800-853-9535
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 65730
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C005319
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License Number State | NC
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