Healthcare Provider Details

I. General information

NPI: 1972256592
Provider Name (Legal Business Name): CAMILLE OLIVIA HENKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 PIERCE ST STE 200
RIVERSIDE CA
92505-4400
US

IV. Provider business mailing address

4785 MERRILL AVE
RIVERSIDE CA
92506-2362
US

V. Phone/Fax

Practice location:
  • Phone: 951-363-0200
  • Fax:
Mailing address:
  • Phone: 951-232-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: