Provider Demographics
NPI:1962740027
Name:CAMACHO- CORDOBA, RENE ENRIQUE
Entity type:Individual
Prefix:MR
First Name:RENE
Middle Name:ENRIQUE
Last Name:CAMACHO- CORDOBA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RENE
Other - Middle Name:ENRIQUE
Other - Last Name:CAMACHO-CORDOBA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC, CASAC
Mailing Address - Street 1:4740 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5839
Mailing Address - Country:US
Mailing Address - Phone:954-486-4005
Mailing Address - Fax:
Practice Address - Street 1:3440 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2000
Practice Address - Country:US
Practice Address - Phone:954-424-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16892101YA0400X
FLMH16257101YM0800X, 1041C0700X
NY004022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health