Provider Demographics
NPI:1083107635
Name:CAMP, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CAMP
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 1:225 MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2550
Mailing Address - Country:US
Mailing Address - Phone:850-781-0406
Mailing Address - Fax:850-378-5233
Practice Address - Street 1:225 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2550
Practice Address - Country:US
Practice Address - Phone:850-781-0406
Practice Address - Fax:850-378-5233
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
FL103K00000X
FL0-19-10452106E00000X
FL1-20-44510103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1083107635OtherINDIVIDUAL