Provider Demographics
NPI:1609608587
Name:ROQUE AVILA, ISMARY
Entity type:Individual
Prefix:
First Name:ISMARY
Middle Name:
Last Name:ROQUE AVILA
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 1:372 LOPEZ PL
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-3534
Mailing Address - Country:US
Mailing Address - Phone:786-965-0613
Mailing Address - Fax:
Practice Address - Street 1:372 LOPEZ PL
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3534
Practice Address - Country:US
Practice Address - Phone:786-965-0613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-367773106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician