Provider Demographics
NPI:1700583028
Name:MENA QUIROGA, CAMILA SELYNE
Entity Type:Individual
Prefix:
First Name:CAMILA
Middle Name:SELYNE
Last Name:MENA QUIROGA
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 1:5320 NW 12TH CT
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-6419
Mailing Address - Country:US
Mailing Address - Phone:786-450-9137
Mailing Address - Fax:
Practice Address - Street 1:5320 NW 12TH CT
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-6419
Practice Address - Country:US
Practice Address - Phone:786-450-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-253719106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician