Basic Information
| Provider Information | |||||||||
| NPI: | 1487106191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIELDS | ||||||||
| FirstName: | CAMERON | ||||||||
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| Credential: | CDCA.164376 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 COOK RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5136952952 | ||||||||
| Practice Location | |||||||||
| Address1: | 953 S SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373834441 | ||||||||
| FaxNumber: | 9373832916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2016 | ||||||||
| LastUpdateDate: | 07/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.164376 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0267086 | 05 | OH | MEDICAID |