Basic Information
| Provider Information | |||||||||
| NPI: | 1033326301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAMAS PROFESSIONAL COUNSELING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 N STATE ST | ||||||||
| Address2: | PO BOX 627 | ||||||||
| City: | GRANGEVILLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835301769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089830235 | ||||||||
| FaxNumber: | 2089830245 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | GRANGEVILLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835301769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089830235 | ||||||||
| FaxNumber: | 2089830245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | EVERSON | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2089830235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ID | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 807098900 | 05 | ID | MEDICAID | 807099000 | 05 | ID | MEDICAID | 807068800 | 05 | ID | MEDICAID | 807353600 | 05 | ID | MEDICAID | 807068700 | 05 | ID | MEDICAID |