Provider Demographics
NPI:1750828091
Name:ROOSEVELT, DELTA
Entity Type:Individual
Prefix:
First Name:DELTA
Middle Name:
Last Name:ROOSEVELT
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 1:12112 GOLDENSTAR LN
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6679
Mailing Address - Country:US
Mailing Address - Phone:352-874-0002
Mailing Address - Fax:
Practice Address - Street 1:1809 E BROADWAY ST # 122
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8597
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:407-792-5693
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician