Healthcare Provider Details

I. General information

NPI: 1780150276
Provider Name (Legal Business Name): CAMARILLO CENTER FOR INDIVIDUAL AND FAMILY COUNSELING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CARMEN DR STE 102
CAMARILLO CA
93010-3103
US

IV. Provider business mailing address

1601 CARMEN DR STE 102
CAMARILLO CA
93010-3103
US

V. Phone/Fax

Practice location:
  • Phone: 805-625-3786
  • Fax: 805-427-9047
Mailing address:
  • Phone: 805-625-3786
  • Fax: 805-427-9047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LESLIE ELIZABETH MIRANDA
Title or Position: PRESIDENT
Credential:
Phone: 805-625-3786