Provider Demographics
NPI:1992487607
Name:ROQUE, RAFAELLA
Entity type:Individual
Prefix:
First Name:RAFAELLA
Middle Name:
Last Name:ROQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S MAIN ST STE 249
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1243
Mailing Address - Country:US
Mailing Address - Phone:575-527-6093
Mailing Address - Fax:575-527-5886
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1243
Practice Address - Country:US
Practice Address - Phone:575-527-6093
Practice Address - Fax:575-527-5886
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLPCF23033235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist