MEDICARE: SHERECE SHADAE CAMPBELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

General Provider Information

NPI Number	:	1760998306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERECE SHADAE CAMPBELL

Provider Business Mailing Address
First Line	:	9138 LEELAND ARCHER BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-8838
Country	:	US
Telephone Number	:	407-223-1298
Fax Number	:

Provider Business Practice Location Address
First Line	:	9138 LEALAND ARCHER BOULEVARD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-3283
Country	:	US
Telephone Number	:	407-223-1298
Fax Number	:	407-223-1298

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	06/11/2019

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