Provider Demographics
NPI:1760253553
Name:COTO ROQUE, ANA MARY
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:MARY
Last Name:COTO 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 1:7140 NW 179TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5432
Mailing Address - Country:US
Mailing Address - Phone:786-909-5744
Mailing Address - Fax:
Practice Address - Street 1:7140 NW 179TH ST APT 205
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5432
Practice Address - Country:US
Practice Address - Phone:786-909-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-320025106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician