Provider Demographics
NPI:1053827121
Name:CAMACHO, IRISMAR
Entity Type:Individual
Prefix:
First Name:IRISMAR
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRISMAR
Other - Middle Name:TERESA
Other - Last Name:CAMACHO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10773 NW 58TH ST # 223
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2801
Mailing Address - Country:US
Mailing Address - Phone:786-712-7452
Mailing Address - Fax:
Practice Address - Street 1:10773 NW 58TH ST # 223
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2801
Practice Address - Country:US
Practice Address - Phone:786-712-7452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty