Basic Information
| Provider Information | |||||||||
| NPI: | 1891964342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1361 S RIMHURST AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268626706 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11001 E. V ALLEY MALL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264420710 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS23942 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | ICAN797 | 01 | CA | LOS ANGELES COUNTY DMH | OTHER |