Provider Demographics
NPI:1487100723
Name:SERGUERA, RAQUEL
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:SERGUERA
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 1:3531 NW 170 ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-4128
Mailing Address - Country:US
Mailing Address - Phone:561-667-4903
Mailing Address - Fax:
Practice Address - Street 1:175 FONTAINEBLEAU BOULEVARD
Practice Address - Street 2:SUIT 2D1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172
Practice Address - Country:US
Practice Address - Phone:305-228-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-16-15157106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician