Provider Demographics
NPI:1558088328
Name:CAMILO, BENITA WHITE (LCMHCA)
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:WHITE
Last Name:CAMILO
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 REAGAN DR STE 14
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-1395
Mailing Address - Country:US
Mailing Address - Phone:704-332-8787
Mailing Address - Fax:704-332-8788
Practice Address - Street 1:5108 REAGAN DR STE 14
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-1395
Practice Address - Country:US
Practice Address - Phone:704-332-8787
Practice Address - Fax:704-332-8788
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18155101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional