Basic Information
| Provider Information | |||||||||
| NPI: | 1053567701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 649 E ALBERTONI ST | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907461538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104369300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 649 E ALBERTONI ST | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907461538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104369300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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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 | 106H00000X | 70768 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.