Basic Information
| Provider Information | |||||||||
| NPI: | 1063731859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | CARMENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LMHC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2801 NE 183RD ST | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331602100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059313845 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1065 NE 125TH ST | ||||||||
| Address2: | STE 206 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2010 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH8861 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 002667200 | 05 | FL | MEDICAID |