Healthcare Provider Details

I. General information

NPI: 1154778058
Provider Name (Legal Business Name): ALICIA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 W 68TH ST UNIT # 138
HIALEAH FL
33018-1736
US

IV. Provider business mailing address

3355 W 68TH ST UNIT # 138
HIALEAH FL
33018-1736
US

V. Phone/Fax

Practice location:
  • Phone: 305-803-9932
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13878
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49519
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: