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General NPI Number Information
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NPI Number | 1255972246
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Entity Type | Individual
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Provider Name | CAMILLE CELESTE ROCHA-WALLACE
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Gender | Female
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Dates
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Enumeration Date | 10/01/2019
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Last Update Date | 03/10/2021
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Provider Practice Location Address
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Address Line | 2769 VALENCIA RD
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City | APTOS
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State | CA
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Zip | 95003-9616
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Country | US
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Telephone | 831-889-8100
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Fax |
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Provider Business Mailing Address
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Address Line | 2769 VALENCIA RD
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City | APTOS
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State | CA
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Zip | 95003-9616
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Country | US
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Telephone | 831-889-8100
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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