MEDICARE: RICQUEL RAYUANA ROLLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YM0800X	Mental Health Counselor		PA

General Provider Information

NPI Number	:	1427719806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICQUEL RAYUANA ROLLE

Provider Business Mailing Address
First Line	:	1415 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-3323
Country	:	US
Telephone Number	:	223-229-3814
Fax Number	:	484-452-3575

Provider Business Practice Location Address
First Line	:	1415 N BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19122-3323
Country	:	US
Telephone Number	:	223-229-3814
Fax Number	:	484-452-3575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	01/06/2022

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