=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164262655
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMILLE ANDERSON ACMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 532 E 800 N BLDG 2
-----------------------------------------------------
City | OREM
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84097-4146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-230-7998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 W 1460 N
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-602-3147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 14001150-6009
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------