Provider Demographics
NPI:1154151504
Name:PHILLIPS, CAMERON VANDER
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:VANDER
Last Name:PHILLIPS
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 1:2808 CARPENTER POND RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-8162
Mailing Address - Country:US
Mailing Address - Phone:919-390-8896
Mailing Address - Fax:
Practice Address - Street 1:1011 DRESSER CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7323
Practice Address - Country:US
Practice Address - Phone:919-390-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20402101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health