Provider Demographics
NPI:1114495025
Name:ISAZA, CAMILO
Entity Type:Individual
Prefix:
First Name:CAMILO
Middle Name:
Last Name:ISAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3022
Mailing Address - Country:US
Mailing Address - Phone:718-536-2958
Mailing Address - Fax:
Practice Address - Street 1:147 PRINCE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3022
Practice Address - Country:US
Practice Address - Phone:704-536-2958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSMedicaid