Provider Demographics
NPI:1861138430
Name:ROUNDTREE, SEIRRA DIAMOND
Entity type:Individual
Prefix:MS
First Name:SEIRRA
Middle Name:DIAMOND
Last Name:ROUNDTREE
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 1:3400 HOLLYWOOD BLVD STE 415
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6911
Mailing Address - Country:US
Mailing Address - Phone:800-617-9620
Mailing Address - Fax:
Practice Address - Street 1:4920 EUCALYPTUS DR UNIT 2
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-7097
Practice Address - Country:US
Practice Address - Phone:786-661-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10066768ZMedicaid