MEDICARE: CAMERON PARK COUNSELING CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS10219	CA
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1477760874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMERON PARK COUNSELING CENTER, INC.

Provider Business Mailing Address
First Line	:	970 CAMERADO DR STE 200
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-7636
Country	:	US
Telephone Number	:	530-677-4404
Fax Number	:	530-677-4545

Provider Business Practice Location Address
First Line	:	970 CAMERADO DR STE 200
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-7636
Country	:	US
Telephone Number	:	530-677-4404
Fax Number	:	530-677-4545

Authorized Official
Title or Position	:	OWNER, CLINICAL DIRECTOR
Name	:	ROSE-MARIE Y NIETO
Credential	:	LCSW
Telephone Number	:	530-677-4404

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	03/07/2023

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