Provider Demographics
NPI:1063119295
Name:ROQUE, RICHARD IVAN (MSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:IVAN
Last Name:ROQUE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 4 BOX 48004
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-8457
Mailing Address - Country:US
Mailing Address - Phone:787-356-2056
Mailing Address - Fax:
Practice Address - Street 1:ISAAC GONZALEZ ESQUINA LEDESMA CLL
Practice Address - Street 2:
Practice Address - City:UTUADO
Practice Address - State:PR
Practice Address - Zip Code:00641-0001
Practice Address - Country:US
Practice Address - Phone:787-356-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR160881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical