Provider Demographics
NPI:1144770348
Name:GOODRUM, CAMAY ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:CAMAY
Middle Name:ALEXANDRIA
Last Name:GOODRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 OAKLAND SHORES DR APT G104
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5618
Mailing Address - Country:US
Mailing Address - Phone:954-702-7449
Mailing Address - Fax:
Practice Address - Street 1:433 PLAZA REAL STE 275
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3999
Practice Address - Country:US
Practice Address - Phone:561-350-8592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCAMGOO052916106S00000X
FLBACB369399106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician