Provider Demographics
NPI:1073256897
Name:NUTTALL, CAMILLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:NUTTALL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 RUNNYMEDE ST
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1333
Mailing Address - Country:US
Mailing Address - Phone:630-470-5933
Mailing Address - Fax:
Practice Address - Street 1:3555 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist