Provider Demographics
NPI:1881281616
Name:HERNANDEZ ROA, ROBERTO
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:HERNANDEZ ROA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 NW 151ST ST STE 214
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2451
Mailing Address - Country:US
Mailing Address - Phone:786-681-8494
Mailing Address - Fax:
Practice Address - Street 1:5901 NW 151ST ST STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2451
Practice Address - Country:US
Practice Address - Phone:786-681-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121234106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid