Provider Demographics
NPI:1982230207
Name:ROQUE, LIZETTE
Entity Type:Individual
Prefix:
First Name:LIZETTE
Middle Name:
Last Name: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 1:7975 LAKE UNDERHILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8204
Mailing Address - Country:US
Mailing Address - Phone:407-303-6830
Mailing Address - Fax:407-303-6839
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8204
Practice Address - Country:US
Practice Address - Phone:407-303-6830
Practice Address - Fax:407-303-6839
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical