Provider Demographics
NPI:1922635259
Name:ANDERSON, CAMILLE MAELA
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MAELA
Last Name:ANDERSON
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 1:523 LYNN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2526 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2333
Practice Address - Country:US
Practice Address - Phone:434-836-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119-008566OtherVA LICENSE