Healthcare Provider Details

I. General information

NPI: 1982230207
Provider Name (Legal Business Name): LIZETTE ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7975 LAKE UNDERHILL RD STE 200
ORLANDO FL
32822-8204
US

IV. Provider business mailing address

7975 LAKE UNDERHILL RD STE 200
ORLANDO FL
32822-8204
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-6830
  • Fax: 407-303-6839
Mailing address:
  • Phone: 407-303-6830
  • Fax: 407-303-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY11364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: