=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598098006
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON ROQUEMORE ED.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2009
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 S 13TH ST
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30224-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-760-5365
-----------------------------------------------------
Fax | 866-217-7073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 748 HIGHWAY 36 E
-----------------------------------------------------
City | BARNESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30204-3248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-760-5365
-----------------------------------------------------
Fax | 866-217-7073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT000232
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC000524
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------