Provider Demographics
NPI:1295003275
Name:CAMERON, CONNIE J
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:CAMERON
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 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-246-1210
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:116 W 7TH AVE STE 222
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4050
Practice Address - Country:US
Practice Address - Phone:918-225-0540
Practice Address - Fax:918-225-0536
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028322101YP2500X
101Y00000X
OK5496101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170 GMedicaid