Provider Demographics
NPI:1356102297
Name:CAMACHO, KRISTEN T
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:T
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:TARA
Other - Last Name:SOOKLAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6810 N STATE ROAD 7 STE 300
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-4304
Mailing Address - Country:US
Mailing Address - Phone:954-801-5506
Mailing Address - Fax:
Practice Address - Street 1:6810 N STATE ROAD 7 STE 300
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-4304
Practice Address - Country:US
Practice Address - Phone:954-801-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4872106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist