Provider Demographics
NPI:1346793551
Name:SUMMERS, CAMILLE DAWN (MA BCBA)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:DAWN
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:DAWN
Other - Last Name:SUMMERS-GODFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA BCBA
Mailing Address - Street 1:474 BLOSSOM HILL RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3301
Mailing Address - Country:US
Mailing Address - Phone:831-464-8798
Mailing Address - Fax:
Practice Address - Street 1:474 BLOSSOM HILL RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3301
Practice Address - Country:US
Practice Address - Phone:408-826-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11415334103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst