Healthcare Provider Details

I. General information

NPI: 1366095499
Provider Name (Legal Business Name): CIERRA NICOLE CAMON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 PONDELLA RD STE 9
N FT MYERS FL
33903-4340
US

IV. Provider business mailing address

12505 MCGREGOR BLVD APT 211
FORT MYERS FL
33919-3185
US

V. Phone/Fax

Practice location:
  • Phone: 239-652-0260
  • Fax: 239-652-0146
Mailing address:
  • Phone: 941-676-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: