=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548621030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FOURMULA CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2016
-----------------------------------------------------
Last Update Date | 08/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5499 N FEDERAL HWY
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33487-4993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-617-1925
-----------------------------------------------------
Fax | 561-617-1928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5499 N FEDERAL HWY
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33487-4993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-617-1925
-----------------------------------------------------
Fax | 561-617-1928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MISS ROBIN LEIGH GUTERMAN-PERRY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 561-617-1925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | SW10458
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | SW10458
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | SW10458
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------