Provider Demographics
NPI:1548621030
Name:THE FOURMULA CENTER, LLC
Entity type:Organization
Organization Name:THE FOURMULA CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GUTERMAN-PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:561-617-1925
Mailing Address - Street 1:5499 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4993
Mailing Address - Country:US
Mailing Address - Phone:561-617-1925
Mailing Address - Fax:561-617-1928
Practice Address - Street 1:5499 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4993
Practice Address - Country:US
Practice Address - Phone:561-617-1925
Practice Address - Fax:561-617-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW10458261QM0850X, 261QM0855X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health