Basic Information
| Provider Information | |||||||||
| NPI: | 1174072284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SILVA | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624013032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173477179 | ||||||||
| FaxNumber: | 2173426716 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU SAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535781541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086433147 | ||||||||
| FaxNumber: | 6086433178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2016 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6963-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1174072284 | 05 | WI | MEDICAID |