Basic Information
| Provider Information | |||||||||
| NPI: | 1538418728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMACHO | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORENO | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | IMF (CA) | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1913 SANDALWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934552863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057203991 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 W CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934584303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059222243 | ||||||||
| FaxNumber: | 8053498165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2012 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 76038 | CA | N | Other Service Providers | Case Manager/Care Coordinator | 106H00000X | 113702 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | 76038 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 76038 | 01 | CA | IMF CALIFORNIA | OTHER | 113702 | 01 | CA | AMFT CALIFORNIA | OTHER |