Provider Demographics
NPI:1629325097
Name:DELONG, CAMILLE (BS MS LMFT)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:BS MS LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2284
Mailing Address - Country:US
Mailing Address - Phone:180-131-7904
Mailing Address - Fax:180-136-4368
Practice Address - Street 1:275 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1247
Practice Address - Country:US
Practice Address - Phone:180-153-1738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1142433902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist