Provider Demographics
NPI:1417440884
Name:CAMACHO, DYLAN (LPCC)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUWANNEE TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7956
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:1900 SMALLHOUSE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3270
Practice Address - Country:US
Practice Address - Phone:270-303-5292
Practice Address - Fax:270-596-0837
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173714101Y00000X
KY263107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid