Provider Demographics
NPI:1598114324
Name:CAMPOS, MARTHA LIDIA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LIDIA
Last Name:CAMPOS
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 1:18301 S DIXIE HWY PH 507
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5569
Mailing Address - Country:US
Mailing Address - Phone:786-278-8620
Mailing Address - Fax:
Practice Address - Street 1:18301 S DIXIE HWY PH 507
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5569
Practice Address - Country:US
Practice Address - Phone:786-278-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15-09611106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician