Provider Demographics
NPI:1396461141
Name:MIRANDA ROQUE, YAMISELA (RBT)
Entity type:Individual
Prefix:
First Name:YAMISELA
Middle Name:
Last Name:MIRANDA ROQUE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15331 SW 143RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-2879
Mailing Address - Country:US
Mailing Address - Phone:561-635-1674
Mailing Address - Fax:
Practice Address - Street 1:15331 SW 143RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-2879
Practice Address - Country:US
Practice Address - Phone:561-635-1674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-24-77442103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115952900Medicaid