Provider Demographics
NPI:1689274334
Name:CARMONA, ROGELIO
Entity Type:Individual
Prefix:
First Name:ROGELIO
Middle Name:
Last Name:CARMONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9813 NW 123RD TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2951
Mailing Address - Country:US
Mailing Address - Phone:305-994-4638
Mailing Address - Fax:
Practice Address - Street 1:5931 NW 173RD DR UNIT 10
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5107
Practice Address - Country:US
Practice Address - Phone:305-826-7884
Practice Address - Fax:305-826-1545
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-104235106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician