Provider Demographics
NPI:1881446805
Name:GARCIA ROLDAN, ANGIES
Entity type:Individual
Prefix:
First Name:ANGIES
Middle Name:
Last Name:GARCIA 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 1:14720 SW 264TH ST APT 304
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7309
Mailing Address - Country:US
Mailing Address - Phone:786-256-7028
Mailing Address - Fax:
Practice Address - Street 1:14720 SW 264TH ST APT 304
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7309
Practice Address - Country:US
Practice Address - Phone:786-256-7028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-327893106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122039500Medicaid