Provider Demographics
NPI:1568233617
Name:CAMACHO DIAZ, GEIDY
Entity Type:Individual
Prefix:
First Name:GEIDY
Middle Name:
Last Name:CAMACHO DIAZ
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 1:5615 FOREST HAVEN CIR APT 206
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3929
Mailing Address - Country:US
Mailing Address - Phone:863-319-2059
Mailing Address - Fax:
Practice Address - Street 1:4940 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1075
Practice Address - Country:US
Practice Address - Phone:813-485-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-311759106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-23-311759OtherRBT