Provider Demographics
NPI:1679332308
Name:HERETH, CAMILLE MARIE (CC)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MARIE
Last Name:HERETH
Suffix:
Gender:F
Credentials:CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8807 72ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-5871
Mailing Address - Country:US
Mailing Address - Phone:425-263-0300
Mailing Address - Fax:
Practice Address - Street 1:8807 72ND ST SE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-5871
Practice Address - Country:US
Practice Address - Phone:425-263-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACL60267779101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health