Healthcare Provider Details

I. General information

NPI: 1245897362
Provider Name (Legal Business Name): CAMILLE INEZ CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 OYSTER POINT RD
NEWPORT NEWS VA
23606-4570
US

IV. Provider business mailing address

811 REDGATE AVE
NORFOLK VA
23507-1515
US

V. Phone/Fax

Practice location:
  • Phone: 804-840-6066
  • Fax:
Mailing address:
  • Phone: 804-840-6066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007626
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: