Provider Demographics
NPI:1083230486
Name:CAMACHO, LIZETT
Entity Type:Individual
Prefix:
First Name:LIZETT
Middle Name:
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 1:1450 NEOTOMAS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7574
Mailing Address - Country:US
Mailing Address - Phone:707-280-2875
Mailing Address - Fax:
Practice Address - Street 1:145O NEOTOMAS AVENUE SUITE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-280-2875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARH000347019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)