Healthcare Provider Details

I. General information

NPI: 1376859033
Provider Name (Legal Business Name): SHERLLEY YAMIRIE CAMPOS MS, LMHC, CAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-2313
US

IV. Provider business mailing address

PO BOX 423202
KISSIMMEE FL
34742-3202
US

V. Phone/Fax

Practice location:
  • Phone: 407-957-9077
  • Fax: 888-702-0079
Mailing address:
  • Phone: 407-957-9077
  • Fax: 888-702-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAP2955
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 11107
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: