Provider Demographics
NPI:1285229104
Name:ROQUE MARTINEZ, ELAINE MARIA
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIA
Last Name:ROQUE MARTINEZ
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 1:2400 NW 16TH STREET RD APT 208
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1252
Mailing Address - Country:US
Mailing Address - Phone:786-541-6936
Mailing Address - Fax:
Practice Address - Street 1:14425 COUNTRY WALK DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-8103
Practice Address - Country:US
Practice Address - Phone:786-349-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140665106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty