Provider Demographics
NPI:1518791722
Name:SOBRINO JIMENEZ, ROXANA
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:SOBRINO JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8358 MARTINGALE DR APT 206
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-8134
Mailing Address - Country:US
Mailing Address - Phone:754-268-0208
Mailing Address - Fax:
Practice Address - Street 1:8358 MARTINGALE DR APT 206
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-8134
Practice Address - Country:US
Practice Address - Phone:754-268-0208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-373380106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty