Provider Demographics
NPI:1134399942
Name:GONZALEZ CAMACHO, BRENDA (LCSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GONZALEZ CAMACHO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 496016
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-6016
Mailing Address - Country:US
Mailing Address - Phone:941-613-1356
Mailing Address - Fax:
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
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW88371041C0700X
FLTN 36567246R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology