Provider Demographics
NPI:1326865338
Name:HENRIQUEZ LEON, CARLA DE LA CARIDAD
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:DE LA CARIDAD
Last Name:HENRIQUEZ LEON
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 1:130 W 40TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4432
Mailing Address - Country:US
Mailing Address - Phone:305-803-8295
Mailing Address - Fax:
Practice Address - Street 1:130 W 40TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4432
Practice Address - Country:US
Practice Address - Phone:305-803-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-379036106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician