Healthcare Provider Details

I. General information

NPI: 1013358217
Provider Name (Legal Business Name): CARLOS IZQUIERDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SUNSET DR STE 114
MIAMI FL
33173-3038
US

IV. Provider business mailing address

3900 NW 79TH AVE SUITE 501
DORAL FL
33166-6556
US

V. Phone/Fax

Practice location:
  • Phone: 305-508-5580
  • Fax: 772-675-9100
Mailing address:
  • Phone: 305-597-3861
  • Fax: 305-597-3863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH217224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: