Healthcare Provider Details

I. General information

NPI: 1568060556
Provider Name (Legal Business Name): ADDIS ROQUE CABRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 NW 123RD AVE
PEMBROKE PINES FL
33026-3825
US

IV. Provider business mailing address

21960 SW 124TH AVE
MIAMI FL
33170-2702
US

V. Phone/Fax

Practice location:
  • Phone: 954-589-5697
  • Fax:
Mailing address:
  • Phone: 772-828-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-138587
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: