Provider Demographics
NPI:1922759802
Name:CAMILLE, CHINONYEREM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CHINONYEREM
Middle Name:
Last Name:CAMILLE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 STATE ST STE 225
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7632
Mailing Address - Country:US
Mailing Address - Phone:866-839-6979
Mailing Address - Fax:
Practice Address - Street 1:180 STATE ST STE 225
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7632
Practice Address - Country:US
Practice Address - Phone:866-839-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1209026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist