Provider Demographics
NPI:1609639905
Name:DEBRUIN, CAMILLE
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:DEBRUIN
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 1:11395 ELIANO ST
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-6159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 JAMES WAY STE 150
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2877
Practice Address - Country:US
Practice Address - Phone:805-769-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142606106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist