Provider Demographics
NPI:1871075457
Name:CAMACHO, REBECCA SHELLEY
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SHELLEY
Last Name: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 1:2535 KETTNER BLVD STE 1A4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1252
Mailing Address - Country:US
Mailing Address - Phone:619-615-0701
Mailing Address - Fax:
Practice Address - Street 1:2535 KETTNER BLVD STE 1A4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1252
Practice Address - Country:US
Practice Address - Phone:619-615-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2024-09-10
Deactivation Date:2024-05-02
Deactivation Code:
Reactivation Date:2024-06-13
Provider Licenses
StateLicense IDTaxonomies
IL125084180207R00000X, 207Q00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine