Provider Demographics
NPI:1568232965
Name:ROQUE, LARITZA
Entity Type:Individual
Prefix:
First Name:LARITZA
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 1:21 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-2656
Mailing Address - Country:US
Mailing Address - Phone:305-305-9769
Mailing Address - Fax:
Practice Address - Street 1:1140 W 50TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3440
Practice Address - Country:US
Practice Address - Phone:305-231-3371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-318402106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty