Provider Demographics
NPI:1619708617
Name:ROQUE, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
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 1:144 DAVID DR APT 8
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-2860
Mailing Address - Country:US
Mailing Address - Phone:440-830-0402
Mailing Address - Fax:
Practice Address - Street 1:1530 W RIVER RD N
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2791
Practice Address - Country:US
Practice Address - Phone:440-324-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator