Provider Demographics
NPI:1699582296
Name:MEDINA ROLDAN, RAQUEL ENID (RBT-24-391837)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:ENID
Last Name:MEDINA ROLDAN
Suffix:
Gender:F
Credentials:RBT-24-391837
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 GRETNA LN
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-6179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 GRETNA LN
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-6179
Practice Address - Country:US
Practice Address - Phone:787-394-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-391837106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician