Basic Information
| Provider Information | |||||||||
| NPI: | 1942855754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CAMILLE | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDREN'S DRIVE | ||||||||
| Address2: | PSYCHOLOGY DEPARTMENT | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147224700 | ||||||||
| FaxNumber: | 6147224718 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHILDREN'S DRIVE | ||||||||
| Address2: | PSYCHOLOGY DEPARTMENT | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147224700 | ||||||||
| FaxNumber: | 6147224718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | P07903 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |