Basic Information
| Provider Information | |||||||||
| NPI: | 1316213176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOLISTIC COGNITIVE THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 PONCE DE LEON BLVD | ||||||||
| Address2: | SUITE 318 | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054428833 | ||||||||
| FaxNumber: | 3054636693 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 PONCE DE LEON BLVD | ||||||||
| Address2: | SUITE 318 | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054428833 | ||||||||
| FaxNumber: | 3054636693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | LARRAIN | ||||||||
| AuthorizedOfficialFirstName: | FLORENCIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3054428833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH6882 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH6882 | 01 | FL | STATE LICENSE | OTHER |