Provider Demographics
NPI:1659792299
Name:STANICK, CAMEO FAITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAMEO
Middle Name:FAITH
Last Name:STANICK
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 1:1139 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-2518
Mailing Address - Country:US
Mailing Address - Phone:406-493-2765
Mailing Address - Fax:
Practice Address - Street 1:1139 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2518
Practice Address - Country:US
Practice Address - Phone:406-493-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-29
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1333103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist