Provider Demographics
NPI:1265262638
Name:ROQUE, DERRYCK WINSTON ADAO (COUNSELOR)
Entity type:Individual
Prefix:
First Name:DERRYCK WINSTON
Middle Name:ADAO
Last Name:ROQUE
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W SYBELIA AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 W SYBELIA AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4739
Practice Address - Country:US
Practice Address - Phone:407-865-0495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH23502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health