Provider Demographics
NPI:1932602349
Name:PAVLICEK-FAUSER, CAMILLE MARIE
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:MARIE
Last Name:PAVLICEK-FAUSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-4200
Mailing Address - Country:US
Mailing Address - Phone:330-676-8057
Mailing Address - Fax:330-678-3677
Practice Address - Street 1:3920 LOVERS LN
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-4200
Practice Address - Country:US
Practice Address - Phone:330-676-8057
Practice Address - Fax:330-678-3677
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC3673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health