Provider Demographics
NPI:1174612881
Name:JIMENEZ, CARMEN RUEDA (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:RUEDA
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 LORETTO AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2105
Mailing Address - Country:US
Mailing Address - Phone:786-205-1758
Mailing Address - Fax:
Practice Address - Street 1:461 LORETTO AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2105
Practice Address - Country:US
Practice Address - Phone:786-205-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076180000Medicaid