Basic Information
| Provider Information | |||||||||
| NPI: | 1104585801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | OWEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 291943 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372291943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8339520829 | ||||||||
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| Practice Location | |||||||||
| Address1: | 409 ALFRED ST UNIT 4 | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040053756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8333564080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2021 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | XL6465 | ME | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.