Provider Demographics
NPI:1831428838
Name:CENTER FOR HUMAN FORMATION, LLC
Entity type:Organization
Organization Name:CENTER FOR HUMAN FORMATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:CAMILO
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:786-879-7007
Mailing Address - Street 1:PO BOX 140432
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-0432
Mailing Address - Country:US
Mailing Address - Phone:786-879-7007
Mailing Address - Fax:
Practice Address - Street 1:301 ALMERIA AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-5822
Practice Address - Country:US
Practice Address - Phone:786-879-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty