Provider Demographics
NPI:1134824923
Name:ROLDAN, MAYRA KAYE
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:KAYE
Last Name:ROLDAN
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 1:160 LAIDBACK WAY
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34945-3409
Mailing Address - Country:US
Mailing Address - Phone:772-302-4306
Mailing Address - Fax:
Practice Address - Street 1:160 LAIDBACK WAY
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34945-3409
Practice Address - Country:US
Practice Address - Phone:772-302-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst