Healthcare Provider Details

I. General information

NPI: 1568153062
Provider Name (Legal Business Name): CAMELIA LADJADJ LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4332 W DESERT COVE AVE
GLENDALE AZ
85304-4120
US

IV. Provider business mailing address

4332 W DESERT COVE AVE
GLENDALE AZ
85304-4120
US

V. Phone/Fax

Practice location:
  • Phone: 614-805-3292
  • Fax:
Mailing address:
  • Phone: 614-805-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-23002
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: