Provider Demographics
NPI:1962172767
Name:NIETO ROA, SANDRA ISABEL
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:ISABEL
Last Name:NIETO ROA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5068 AMBLER LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-6632
Mailing Address - Country:US
Mailing Address - Phone:561-891-3049
Mailing Address - Fax:
Practice Address - Street 1:2119 10TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH BEACH
Practice Address - State:FL
Practice Address - Zip Code:33461-3345
Practice Address - Country:US
Practice Address - Phone:561-444-2814
Practice Address - Fax:561-444-2458
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-136336106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician