Healthcare Provider Details

I. General information

NPI: 1639406093
Provider Name (Legal Business Name): CAMELOT COMMUNITY CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 TECH BLVD
TAMPA FL
33619-7865
US

IV. Provider business mailing address

4910 CREEKSIDE DR STE D
CLEARWATER FL
33760-4034
US

V. Phone/Fax

Practice location:
  • Phone: 813-635-9765
  • Fax: 813-635-9725
Mailing address:
  • Phone: 727-593-0003
  • Fax: 727-595-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH 7500
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JANA ALLEN
Title or Position: DIRECTOR OF AR
Credential:
Phone: 727-593-0003