Provider Demographics
NPI:1932275559
Name:MATTHEWS, CAMILLE (LISW BCD)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LISW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 E 20TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-325-6532
Mailing Address - Fax:505-325-0827
Practice Address - Street 1:904 E 20TH ST
Practice Address - Street 2:STE B
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-6532
Practice Address - Fax:505-325-0827
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-41141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00067835Medicaid