=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215307491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL ASSOCIATION OF SOUTH FLORIDA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2015
-----------------------------------------------------
Last Update Date | 10/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 MADRUGA AVE STE 510
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33146-3048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-901-7350
-----------------------------------------------------
Fax | 786-615-2330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11301 S DIXIE HWY UNIT 565392
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33256-7222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-901-7350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIEF PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ROSE CHANTAL HUBER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 305-901-7350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY7973
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------