Provider Demographics
NPI:1063629178
Name:MCCAMBRIDGE, CARLENE MARY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:MARY
Last Name:MCCAMBRIDGE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CARLENE
Other - Middle Name:MARY
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1831 SW PALM CITY ROAD
Mailing Address - Street 2:C301
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994
Mailing Address - Country:US
Mailing Address - Phone:772-777-0391
Mailing Address - Fax:
Practice Address - Street 1:301 CAMINO GARDENS BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432
Practice Address - Country:US
Practice Address - Phone:561-494-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4071225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880791400Medicaid
204299899OtherFEDERAL EMPLOYER ID