Provider Demographics
NPI:1679147938
Name:BIRMINGHAM, CAMERON ANTTWAN
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:ANTTWAN
Last Name:BIRMINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 S BROOKSTONE VILLAGE DR
Mailing Address - Street 2:APT 203
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057
Mailing Address - Country:US
Mailing Address - Phone:816-216-0143
Mailing Address - Fax:
Practice Address - Street 1:1825 S BROOKSTONE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-216-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOA176245003101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
487149633OtherN/A