Provider Demographics
NPI:1922737097
Name:WIEMERSLAGE, CAMERON KEITH (LPC)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:KEITH
Last Name:WIEMERSLAGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 W WESTFIELD PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4651
Mailing Address - Country:US
Mailing Address - Phone:208-914-4645
Mailing Address - Fax:
Practice Address - Street 1:161 E MALLARD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5015
Practice Address - Country:US
Practice Address - Phone:208-605-3657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8797101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional