Healthcare Provider Details

I. General information

NPI: 1134399942
Provider Name (Legal Business Name): BRENDA GONZALEZ CAMACHO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22099 ELMIRA BLVD
PORT CHARLOTTE FL
33952-7018
US

IV. Provider business mailing address

PO BOX 496016
PORT CHARLOTTE FL
33949-6016
US

V. Phone/Fax

Practice location:
  • Phone: 941-613-1356
  • Fax: 941-613-1591
Mailing address:
  • Phone: 941-613-1356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8837
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246R00000X
TaxonomyPathology Technician
License NumberTN 36567
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: