Provider Demographics
NPI:1083923718
Name:CARRASCO, ROMAN MARCUS (PSYD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:MARCUS
Last Name:CARRASCO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E ROLLINS ST # 6
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5502
Mailing Address - Country:US
Mailing Address - Phone:407-821-3584
Mailing Address - Fax:
Practice Address - Street 1:265 E ROLLINS ST # 6
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5502
Practice Address - Country:US
Practice Address - Phone:407-821-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10726103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical