Healthcare Provider Details

I. General information

NPI: 1487548384
Provider Name (Legal Business Name): MS. STEPHANIE ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 SW 36TH AVE STE 207
POMPANO BEACH FL
33069-4838
US

IV. Provider business mailing address

8064 W 15TH CT
HIALEAH FL
33014-3337
US

V. Phone/Fax

Practice location:
  • Phone: 561-408-1098
  • Fax:
Mailing address:
  • Phone: 305-409-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: