Basic Information
| Provider Information | |||||||||
| NPI: | 1043638190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMAK | ||||||||
| FirstName: | KELSI | ||||||||
| MiddleName: | HARPER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 N IRBY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436679414 | ||||||||
| FaxNumber: | 8436671362 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 S EVANDER DR | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295064212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434322935 | ||||||||
| FaxNumber: | 8437994297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 6829 | SC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 405127 | 05 | SC | MEDICAID |