Provider Demographics
NPI:1053840140
Name:SULLIVAN, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:SULLIVAN
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 1:8686 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-1947
Mailing Address - Country:US
Mailing Address - Phone:801-750-9090
Mailing Address - Fax:
Practice Address - Street 1:8686 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-1947
Practice Address - Country:US
Practice Address - Phone:801-709-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT79071956004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT26-4573566Medicaid