Provider Demographics
NPI:1194920108
Name:ROLLINS, RAQUEL A (MA)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:A
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7035 SANTA IRENE CIR
Mailing Address - Street 2:10
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3133
Mailing Address - Country:US
Mailing Address - Phone:562-427-6818
Mailing Address - Fax:
Practice Address - Street 1:100 E WARDLOW RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4417
Practice Address - Country:US
Practice Address - Phone:562-427-6818
Practice Address - Fax:562-427-3367
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52555106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist