Provider Demographics
NPI:1225079627
Name:LEAVER, CAMILLE ANN (MA)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:ANN
Last Name:LEAVER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3173
Mailing Address - Country:US
Mailing Address - Phone:336-471-1604
Mailing Address - Fax:
Practice Address - Street 1:1320 ASHLEY SQ OFC CONDOMINIU
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2919
Practice Address - Country:US
Practice Address - Phone:336-471-1604
Practice Address - Fax:252-537-9199
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2085103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical