Basic Information
| Provider Information | |||||||||
| NPI: | 1114411774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMPBELL THERAPY SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1805 INVERNESS AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489151284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167454045 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1750 E GRAND RIVER AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488234958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167454045 | ||||||||
| FaxNumber: | 5173239531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6167454045 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4101006659 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1154799419 | 05 | MI | MEDICAID |