Provider Demographics
NPI:1053187450
Name:MARTIN CAMACHO, LISET
Entity type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:MARTIN CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1348
Mailing Address - Country:US
Mailing Address - Phone:786-760-6813
Mailing Address - Fax:
Practice Address - Street 1:1001 NW 45TH AVE APT 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-6410
Practice Address - Country:US
Practice Address - Phone:786-760-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-308380106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician