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General NPI Number Information
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NPI Number | 1801405238
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Entity Type | Individual
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Provider Name | CAMERON FOUNTAIN LCDC
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Gender | Male
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Dates
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Enumeration Date | 07/31/2020
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Last Update Date | 07/31/2020
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Provider Practice Location Address
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Address Line | 612 N STORY RD STE 101
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City | IRVING
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State | TX
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Zip | 75061-6764
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Country | US
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Telephone | 469-708-2955
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Fax |
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Provider Business Mailing Address
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Address Line | 8109 SKILLMAN ST APT 3008
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City | DALLAS
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State | TX
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Zip | 75231-2828
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Country | US
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Telephone |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | TX
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