=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912503061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID ROSALIE CAMACHO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2020
-----------------------------------------------------
Last Update Date | 12/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 6TH AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-223-6879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6829 BURNS ST APT D1
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-821-3404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 104785-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------