Basic Information
| Provider Information | |||||||||
| NPI: | 1174037261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCAMP | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CASEY | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1451 DOWELL SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | 8653747317 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 DOWELL SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | 8653747317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2017 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3648 | TN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | Q038547 | 05 | TN | MEDICAID |