Provider Demographics
NPI:1578862207
Name:ROLDAN, DIANA MARCELA
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MARCELA
Last Name:ROLDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:MARCELA
Other - Last Name:ROLDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:883 CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-1948
Mailing Address - Country:US
Mailing Address - Phone:786-312-5827
Mailing Address - Fax:
Practice Address - Street 1:883 CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-1948
Practice Address - Country:US
Practice Address - Phone:786-312-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21898225200000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014924900Medicaid