Provider Demographics
NPI:1982117313
Name:WISSMAN, CAMILLE (ATC)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:WISSMAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4568 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-5607
Mailing Address - Country:US
Mailing Address - Phone:805-452-1751
Mailing Address - Fax:
Practice Address - Street 1:5951 E VILLAGE CENTER LOOP RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2499
Practice Address - Country:US
Practice Address - Phone:858-350-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000225642255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2000022564OtherBOC