Camillia Clark, COUI-9541

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

COUI-9541 Issued in ID

Practice address

452 D St
Idaho Falls, ID 83402-3531

Phone

(208) 552-0355

Fax

(208) 200-3201

NPI assigned

Oct 16, 2023

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Vista Family Services LLC

  • Community/Behavioral Health Agency
  • Idaho Falls, ID
  • NPI 1235353251
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1697414400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1697414400000",
    "number": "1528840584",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "452 D ST",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834023531",
            "telephone_number": "208-552-0355",
            "fax_number": "208-200-3201"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "452 D ST",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834023531",
            "telephone_number": "208-552-0355",
            "fax_number": "208-200-3201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "CAMILLIA",
        "credential": "COUI-9541",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-10-16",
        "last_updated": "2023-10-16",
        "certification_date": "2023-10-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "ID",
            "license": "COUI-9541",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Cibrian Counseling & Wellness Center, LLC
• Rocco P Cifrese, MD
• Cindy Goff, PLLC
• City of Idaho Falls
• Sarah Elizabeth Clancy, DO
• Charity Clark, LCSW
• Daniel Ewing Clark, CRNA
• Deborah Joy Clark
• John Clark, LSW
• Melanie Dawn Clark, O.D.

• Mental Health Counselor in Idaho Falls, ID
• Providers in Idaho Falls, ID by specialty
• Mental Health Counselor in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 16, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.