Basic Information
| Provider Information | |||||||||
| NPI: | 1306077052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5775 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734030775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804901589 | ||||||||
| FaxNumber: | 5804909194 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 B ST SW | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734016418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804901589 | ||||||||
| FaxNumber: | 5804909194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3064 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.