Healthcare Provider Details

I. General information

NPI: 1639153455
Provider Name (Legal Business Name): CAMILLE SEXTON-VILLALTA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 PRO-MED LN
CARMEL IN
46032-5317
US

IV. Provider business mailing address

703 PRO-MED LN
CARMEL IN
46032-5317
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-9922
  • Fax: 317-581-3918
Mailing address:
  • Phone: 317-843-9922
  • Fax: 317-581-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041086A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: