Provider Demographics
NPI:1790433571
Name:HEART, CAMELLIA
Entity Type:Individual
Prefix:
First Name:CAMELLIA
Middle Name:
Last Name:HEART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 MONTROSE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-4226
Mailing Address - Country:US
Mailing Address - Phone:678-200-6327
Mailing Address - Fax:
Practice Address - Street 1:239 MONTROSE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4226
Practice Address - Country:US
Practice Address - Phone:678-200-6327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137339101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health