Basic Information
| Provider Information | |||||||||
| NPI: | 1588814636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH ST STE 409 | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 8777200502 | ||||||||
| Practice Location | |||||||||
| Address1: | 6915 TUTT BLVD STE 110B | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809233591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194451292 | ||||||||
| FaxNumber: | 7195916486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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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 | 101YM0800X | LPC.0014308 | CO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC1900X | 1212 | KS | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC0700X | PSY.0004952 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PSY.0004952 | 01 | CO | LICENSE | OTHER |