Basic Information
| Provider Information | |||||||||
| NPI: | 1376974766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROQUE | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5840 CORPORATE WAY STE 101 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334072040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1903 S CONGRESS AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2013 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT88830 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT28830 | 01 | FL | PT LICENSE | OTHER |