Provider Demographics
NPI:1285676494
Name:ADVANCED MENTAL HEALTH CLINIC INC
Entity Type:Organization
Organization Name:ADVANCED MENTAL HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-480-7839
Mailing Address - Street 1:13055 SW 42ND ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13055 SW 42ND ST STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3470
Practice Address - Country:US
Practice Address - Phone:305-480-7839
Practice Address - Fax:305-480-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL101490261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEO918AOtherMEDICARE PART B
FLEO918AOtherMEDICARE PART B