Healthcare Provider Details

I. General information

NPI: 1952189110
Provider Name (Legal Business Name): ANDREA ROQUE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 TEMPLE TERRACE HWY
TAMPA FL
33637-5853
US

IV. Provider business mailing address

10740 PALM RIVER RD
TAMPA FL
33619-4573
US

V. Phone/Fax

Practice location:
  • Phone: 813-631-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19202
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: