Provider Demographics
NPI:1659766657
Name:SMITH, CAMILLA (LPCA)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2285
Mailing Address - Country:US
Mailing Address - Phone:270-251-3260
Mailing Address - Fax:270-251-3260
Practice Address - Street 1:120 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-2285
Practice Address - Country:US
Practice Address - Phone:270-251-3260
Practice Address - Fax:270-251-3260
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCA00218286101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYLPCCA00218286Medicaid