Basic Information
| Provider Information | |||||||||
| NPI: | 1235553645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, LCDCIII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1946 N 13TH ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197209247 | ||||||||
| FaxNumber: | 4197200304 | ||||||||
| Practice Location | |||||||||
| Address1: | 1946 N 13TH ST STE 420 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197209247 | ||||||||
| FaxNumber: | 4197200304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2014 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.0005211 | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 081220 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2963990 | 05 | OH | MEDICAID |