Provider Demographics
NPI:1336658962
Name:MORA JIMENEZ, CARLA INES
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:INES
Last Name:MORA JIMENEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13035 SW 258TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6934
Mailing Address - Country:US
Mailing Address - Phone:786-545-2358
Mailing Address - Fax:
Practice Address - Street 1:13035 SW 258TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6934
Practice Address - Country:US
Practice Address - Phone:786-545-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty