Provider Demographics
NPI:1760822811
Name:CEVALLOS, ROXANA (LCSW)
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:CEVALLOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 SW 153RD CT APT 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22790 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170-7602
Practice Address - Country:US
Practice Address - Phone:305-235-2626
Practice Address - Fax:305-235-6178
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL191811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114010100Medicaid
FL116946500OtherBEHAVIOR ANALYSIS PROVIDER
FL19181OtherLCSW