Provider Demographics
NPI:1417712886
Name:DE CAMILLO, KATHERINE E (LMT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:DE CAMILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 ELSA ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-3872
Mailing Address - Country:US
Mailing Address - Phone:203-219-7686
Mailing Address - Fax:
Practice Address - Street 1:3933 ELSA ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-3872
Practice Address - Country:US
Practice Address - Phone:203-219-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91245225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist