=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932476934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL CENTER FOR HUMAN RELATIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2011
-----------------------------------------------------
Last Update Date | 11/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9995 SW 72ND ST STE 213
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-275-0045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9995 SW 72ND ST STE 213
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33173-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-275-0045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. LOURDES HERRERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-275-0045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | SS251
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH124
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------