Provider Demographics
NPI:1760641823
Name:LISTER, CAMILLE (OT)
Entity Type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:
Last Name:LISTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3845 W 4700 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-3454
Mailing Address - Country:US
Mailing Address - Phone:801-840-2191
Mailing Address - Fax:801-840-2197
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-3454
Practice Address - Country:US
Practice Address - Phone:801-840-2191
Practice Address - Fax:801-840-2197
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7022275-4201225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand