Healthcare Provider Details

I. General information

NPI: 1821975285
Provider Name (Legal Business Name): KENDRY ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 NE 17TH AVE
CAPE CORAL FL
33909-5410
US

IV. Provider business mailing address

1914 NE 17TH AVE
CAPE CORAL FL
33909-5410
US

V. Phone/Fax

Practice location:
  • Phone: 305-522-7412
  • Fax:
Mailing address:
  • Phone: 305-522-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB1389596
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: