Provider Demographics
NPI:1518531474
Name:CHAMORRO, EDMUNDO JOSE
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:JOSE
Last Name:CHAMORRO
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 1:11373 NW 7TH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-3591
Mailing Address - Country:US
Mailing Address - Phone:786-266-5459
Mailing Address - Fax:
Practice Address - Street 1:11373 NW 7TH ST APT 105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-3591
Practice Address - Country:US
Practice Address - Phone:786-266-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-16
Last Update Date:2021-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-125337106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician