Provider Demographics
NPI:1881970788
Name:CAMPBELL-DIAZ, CARLENE (OT, CLT)
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:
Last Name:CAMPBELL-DIAZ
Suffix:
Gender:F
Credentials:OT, CLT
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 566601
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33256-6601
Mailing Address - Country:US
Mailing Address - Phone:786-295-7101
Mailing Address - Fax:
Practice Address - Street 1:7600 SW 57TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-5428
Practice Address - Country:US
Practice Address - Phone:786-295-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0T2220225XP0019X, 225XM0800X, 225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics