Healthcare Provider Details

I. General information

NPI: 1760822811
Provider Name (Legal Business Name): ROXANA P. CEVALLOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22790 SW 112TH AVE
MIAMI FL
33170-7602
US

IV. Provider business mailing address

7640 SW 153RD CT APT 101
MIAMI FL
33193-1794
US

V. Phone/Fax

Practice location:
  • Phone: 305-235-2626
  • Fax: 305-235-6178
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW19181
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19181
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: