Healthcare Provider Details

I. General information

NPI: 1205659919
Provider Name (Legal Business Name): MRS. MONICA NURURDIN CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2024
Last Update Date: 11/02/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 LAKE HOWELL RD
MAITLAND FL
32751-5900
US

IV. Provider business mailing address

414 LAKE HOWELL RD
MAITLAND FL
32751-5900
US

V. Phone/Fax

Practice location:
  • Phone: 407-637-2633
  • Fax: 407-558-3438
Mailing address:
  • Phone: 407-637-2633
  • Fax: 407-558-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH25538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: