MEDICARE: CAMELOT COMMUNITY CARE

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	251S00000X	Community/Behavioral Health Agency	MH11357	FL

General Provider Information

NPI Number	:	1881942928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMELOT COMMUNITY CARE

Provider Business Mailing Address
First Line	:	1925 S. PERIMETER ROAD
Second Line	:	SUITE 120
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33309
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1925 S PERIMETER RD
Second Line	:	SUITE 120
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-7122
Country	:	US
Telephone Number	:	954-958-0988
Fax Number	:	954-958-3527

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. MICHELE DISORBO
Credential	:	LMHC
Telephone Number	:	954-958-0988

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	08/21/2012

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