Provider Demographics
NPI:1821658436
Name:CAMACHO, DEJA SHANTE
Entity Type:Individual
Prefix:
First Name:DEJA
Middle Name:SHANTE
Last Name:CAMACHO
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 1:1661 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1826
Mailing Address - Country:US
Mailing Address - Phone:805-264-2005
Mailing Address - Fax:
Practice Address - Street 1:6500 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4142
Practice Address - Country:US
Practice Address - Phone:805-461-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)