Provider Demographics
NPI:1083588503
Name:CAMELLIA COLLECTIVE LLC
Entity type:Organization
Organization Name:CAMELLIA COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-203-5389
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:WEST WARDSBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05360-0363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:146 PIKE HOLLOW RD
Practice Address - Street 2:
Practice Address - City:STRATTON
Practice Address - State:VT
Practice Address - Zip Code:05360-9756
Practice Address - Country:US
Practice Address - Phone:609-203-5389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty