Healthcare Provider Details

I. General information

NPI: 1194082636
Provider Name (Legal Business Name): SHERRY L CAMACHO LCDC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

IV. Provider business mailing address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-6842
  • Fax: 937-548-8938
Mailing address:
  • Phone: 937-548-6842
  • Fax: 937-548-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number111358
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: