Provider Demographics
NPI:1154340768
Name:ROACH, THEODUS MARQUES (LCSW)
Entity type:Individual
Prefix:
First Name:THEODUS
Middle Name:MARQUES
Last Name:ROACH
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 SEBASTIAN CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-3688
Mailing Address - Country:US
Mailing Address - Phone:980-338-5563
Mailing Address - Fax:800-853-9535
Practice Address - Street 1:210 POSTAGE WAY #1772
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9701
Practice Address - Country:US
Practice Address - Phone:980-338-5563
Practice Address - Fax:704-228-0260
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX657301041C0700X
NCC0053191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106359Medicaid