Healthcare Provider Details

I. General information

NPI: 1285393942
Provider Name (Legal Business Name): REBECCACAMPOSLCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WILMONT PL
FORT MYERS FL
33916-8006
US

IV. Provider business mailing address

4101 WILMONT PL
FORT MYERS FL
33916-8006
US

V. Phone/Fax

Practice location:
  • Phone: 203-810-9817
  • Fax:
Mailing address:
  • Phone: 203-810-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: REBECCA HERNANDEZ-CAMPOS
Title or Position: OWNER
Credential: LCSW
Phone: 203-810-9817