Provider Demographics
NPI:1912661240
Name:CARMENATES ROSELLO, SHAKIRA
Entity type:Individual
Prefix:
First Name:SHAKIRA
Middle Name:
Last Name:CARMENATES ROSELLO
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 1:13703 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-6650
Mailing Address - Country:US
Mailing Address - Phone:786-458-7645
Mailing Address - Fax:
Practice Address - Street 1:13703 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6650
Practice Address - Country:US
Practice Address - Phone:786-458-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB505706106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111964600Medicaid