Provider Demographics
NPI:1689707861
Name:ROATTA, VICTORIA G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:G
Last Name:ROATTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-3001
Mailing Address - Country:US
Mailing Address - Phone:305-519-7587
Mailing Address - Fax:305-675-8529
Practice Address - Street 1:1550 MADRUGA AVE STE 319
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-3071
Practice Address - Country:US
Practice Address - Phone:205-519-7587
Practice Address - Fax:305-675-8529
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54755Medicare ID - Type Unspecified