Provider Demographics
NPI:1003399601
Name:CAMPBELL, JUANITA M (LBSC)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LBSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 S 80TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-1734
Mailing Address - Country:US
Mailing Address - Phone:215-350-9998
Mailing Address - Fax:
Practice Address - Street 1:2911 S 67TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-2604
Practice Address - Country:US
Practice Address - Phone:215-350-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001975106S00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician