Provider Demographics
NPI: | 1659348936 |
---|---|
Name: | LOKKEN, CAMI R (PHD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CAMI |
Middle Name: | R |
Last Name: | LOKKEN |
Suffix: | |
Gender: | F |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 445 S LANDMARK AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | BLOOMINGTON |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47403-5004 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-353-3450 |
Mailing Address - Fax: | 812-353-3451 |
Practice Address - Street 1: | 445 S LANDMARK AVE |
Practice Address - Street 2: | |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47403-5004 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-353-3450 |
Practice Address - Fax: | 812-353-3451 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-04 |
Last Update Date: | 2015-01-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 20041123A | 103T00000X, 103TC0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 200141710 | Medicaid | |
000000316234 | Other | ANTHEM | |
IN | 227680E | Medicare ID - Type Unspecified |