Provider Demographics
NPI:1457074247
Name:CLARK, CAMMIE J (ED SPECIALIST)
Entity Type:Individual
Prefix:
First Name:CAMMIE
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:ED SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12911 ROSEMARY ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8408
Mailing Address - Country:US
Mailing Address - Phone:850-630-8887
Mailing Address - Fax:
Practice Address - Street 1:12911 ROSEMARY ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-8408
Practice Address - Country:US
Practice Address - Phone:850-630-8887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool