Provider Demographics
NPI:1639291800
Name:MCCAMISH, MARY LOU
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:MCCAMISH
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 1:18665 MONTROSE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-1449
Mailing Address - Country:US
Mailing Address - Phone:909-421-2659
Mailing Address - Fax:
Practice Address - Street 1:1021 W LA CADENA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1413
Practice Address - Country:US
Practice Address - Phone:951-784-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)