Provider Demographics
NPI:1003367723
Name:CAMPBELL, VICKIE ELLEN
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:ELLEN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:509-684-5286
Practice Address - Street 1:301 E CLAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-8936
Practice Address - Country:US
Practice Address - Phone:509-935-4808
Practice Address - Fax:509-935-4897
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)