Healthcare Provider Details

I. General information

NPI: 1386981652
Provider Name (Legal Business Name): JOSE ENRIQUE ROMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 NW 28TH LN SUITE 6
GAINESVILLE FL
32606-7432
US

IV. Provider business mailing address

5321 NW 78TH LN
GAINESVILLE FL
32653-1163
US

V. Phone/Fax

Practice location:
  • Phone: 352-375-3001
  • Fax:
Mailing address:
  • Phone: 201-406-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW11161
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberLCSW 11161
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: