Basic Information
| Provider Information | |||||||||
| NPI: | 1962740027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO- CORDOBA | ||||||||
| FirstName: | RENE | ||||||||
| MiddleName: | ENRIQUE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CAMACHO-CORDOBA | ||||||||
| OtherFirstName: | RENE | ||||||||
| OtherMiddleName: | ENRIQUE | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMHC, CASAC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3440 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544246911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16892 | NY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | MH16257 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 004022 | NY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | MH16257 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.