Provider Demographics
NPI:1659962256
Name:MACK, CAMILLE ELENA (LMFT)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:ELENA
Last Name:MACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4326
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-4326
Mailing Address - Country:US
Mailing Address - Phone:951-893-7450
Mailing Address - Fax:
Practice Address - Street 1:1220 CRANBROOK AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6047
Practice Address - Country:US
Practice Address - Phone:951-893-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist