Healthcare Provider Details

I. General information

NPI: 1255235883
Provider Name (Legal Business Name): INTEGRATED MENTAL HEALTH SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NW 79TH AVE STE 184
DORAL FL
33122-1083
US

IV. Provider business mailing address

2500 NW 79TH AVE STE 184
DORAL FL
33122-1083
US

V. Phone/Fax

Practice location:
  • Phone: 305-898-4533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARMEN FOUBELO
Title or Position: MGR
Credential: APRN
Phone: 305-898-4533