Healthcare Provider Details

I. General information

NPI: 1619888740
Provider Name (Legal Business Name): KARISSA L CAMARILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W MAIN ST
MEDFORD OR
97501-2728
US

IV. Provider business mailing address

213 EDWARDS ST
MEDFORD OR
97501-5846
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-1777
  • Fax:
Mailing address:
  • Phone: 541-772-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23-CRM-1616
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: