Provider Demographics
NPI:1205307352
Name:DIAZ CAMACHO, XIOMARA ALEJANDRA (PT)
Entity type:Individual
Prefix:
First Name:XIOMARA
Middle Name:ALEJANDRA
Last Name:DIAZ CAMACHO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-2615
Mailing Address - Country:US
Mailing Address - Phone:203-767-4959
Mailing Address - Fax:
Practice Address - Street 1:60 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-7171
Practice Address - Country:US
Practice Address - Phone:203-380-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist