Provider Demographics
NPI:1679896567
Name:CAMELOT OUTPATIENT SERVICES, LLC
Entity Type:Organization
Organization Name:CAMELOT OUTPATIENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-858-9900
Mailing Address - Street 1:4207 E HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4206
Mailing Address - Country:US
Mailing Address - Phone:512-858-9900
Mailing Address - Fax:512-858-9901
Practice Address - Street 1:290 E MONROE ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2336
Practice Address - Country:US
Practice Address - Phone:276-228-7200
Practice Address - Fax:276-228-7100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty