Healthcare Provider Details

I. General information

NPI: 1861108896
Provider Name (Legal Business Name): MIDRELYS ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18736 GALVESTON ST
SPRING HILL FL
34610-7002
US

IV. Provider business mailing address

18736 GALVESTON ST
SPRING HILL FL
34610-7002
US

V. Phone/Fax

Practice location:
  • Phone: 813-516-3616
  • Fax:
Mailing address:
  • Phone: 813-516-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-239817
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: