Provider Demographics
NPI:1003568668
Name:CAMPBELL, AMY RUTH
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:RUTH
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:RUTH
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:5333 MISSION CENTER RD STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1347
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
CA1-21-55509103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician