Provider Demographics
NPI:1043794696
Name:CAMACHO, SAMANTHA ANN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 ELWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-1831
Mailing Address - Country:US
Mailing Address - Phone:781-697-1579
Mailing Address - Fax:
Practice Address - Street 1:1770 PARK ST STE 109
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1244
Practice Address - Country:US
Practice Address - Phone:630-305-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician