Basic Information
| Provider Information | |||||||||
| NPI: | 1417440884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUWANNEE TRAIL ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SMALLHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421043270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703035292 | ||||||||
| FaxNumber: | 2705960837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 173714 | KY | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 263107 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 30604011 | 05 | KY | MEDICAID |