Healthcare Provider Details

I. General information

NPI: 1902734320
Provider Name (Legal Business Name): CAMILLE DIANNE LISTER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 BRUTUS DR
KYLE TX
78640-4647
US

IV. Provider business mailing address

1070 BRUTUS DR
KYLE TX
78640-4647
US

V. Phone/Fax

Practice location:
  • Phone: 361-491-0133
  • Fax:
Mailing address:
  • Phone: 361-491-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number95155
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: