Provider Demographics
NPI:1871034025
Name:BRENDA GONZALEZ CAMACHO LCSW
Entity Type:Organization
Organization Name:BRENDA GONZALEZ CAMACHO LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:941-613-1356
Mailing Address - Street 1:22099 ELMIRA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-7018
Mailing Address - Country:US
Mailing Address - Phone:941-613-1356
Mailing Address - Fax:941-613-1591
Practice Address - Street 1:22099 ELMIRA BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7018
Practice Address - Country:US
Practice Address - Phone:941-613-1356
Practice Address - Fax:941-613-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW88371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty