Provider Demographics
NPI:1770643314
Name:IACAMPO, TAMARA A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:A
Last Name:IACAMPO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7363 HALL ROAD
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:31773
Mailing Address - Country:US
Mailing Address - Phone:229-228-5192
Mailing Address - Fax:229-228-5139
Practice Address - Street 1:7363 HALL ROAD
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:GA
Practice Address - Zip Code:31773
Practice Address - Country:US
Practice Address - Phone:229-228-5192
Practice Address - Fax:229-228-5139
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0032551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA897767470BMedicaid
GAQ40151Medicare UPIN
GA80BBGGBMedicare ID - Type Unspecified