Healthcare Provider Details

I. General information

NPI: 1790316131
Provider Name (Legal Business Name): CAMILLE L SACKETT-WESCOTT OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 CENTRAL AVE
LOS ALAMOS NM
87544-3244
US

IV. Provider business mailing address

976 TSANKAWI ST
LOS ALAMOS NM
87544-2836
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-3384
  • Fax:
Mailing address:
  • Phone: 505-695-4418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT2290
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: