Healthcare Provider Details

I. General information

NPI: 1255972246
Provider Name (Legal Business Name): CAMILLE CELESTE ROCHA-WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2769 VALENCIA RD
APTOS CA
95003-9616
US

IV. Provider business mailing address

2769 VALENCIA RD
APTOS CA
95003-9616
US

V. Phone/Fax

Practice location:
  • Phone: 831-889-8100
  • Fax:
Mailing address:
  • Phone: 831-889-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: