Provider Demographics
NPI:1013358217
Name:IZQUIERDO, CARLOS
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:IZQUIERDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 NW 79TH AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6556
Mailing Address - Country:US
Mailing Address - Phone:305-597-3861
Mailing Address - Fax:305-597-3863
Practice Address - Street 1:10300 SUNSET DR STE 114
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3038
Practice Address - Country:US
Practice Address - Phone:305-508-5580
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
FL390200000X
FLIMH217224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program