Provider Demographics
NPI:1801142518
Name:LIDER, CAMILLE (DPT)
Entity type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:
Last Name:LIDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3476 W 4600 S
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401
Mailing Address - Country:US
Mailing Address - Phone:801-689-0200
Mailing Address - Fax:801-689-0201
Practice Address - Street 1:3476 W 4600 S
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401
Practice Address - Country:US
Practice Address - Phone:801-689-0200
Practice Address - Fax:801-689-0201
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10789141-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801142518OtherNPI
UT10789141-2401OtherUTAH DOPL PT LICENSE
12756913OtherCAQH
UT3008026Medicaid