Provider Demographics
NPI:1861108896
Name:ROQUE, MIDRELYS
Entity type:Individual
Prefix:
First Name:MIDRELYS
Middle Name:
Last Name:ROQUE
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 1:18736 GALVESTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34610-7002
Mailing Address - Country:US
Mailing Address - Phone:813-516-3616
Mailing Address - Fax:
Practice Address - Street 1:18736 GALVESTON ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34610-7002
Practice Address - Country:US
Practice Address - Phone:813-516-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-239817106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician