Provider Demographics
NPI:1013114081
Name:CAMILLA, VICKI JUNE (OTRL)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:JUNE
Last Name:CAMILLA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 ROBARDS POOLE RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-9698
Mailing Address - Country:US
Mailing Address - Phone:270-521-7626
Mailing Address - Fax:
Practice Address - Street 1:25 S BOEHNE CAMP RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-3101
Practice Address - Country:US
Practice Address - Phone:812-423-7468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2519225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN155238Medicaid