Provider Demographics
NPI:1023567799
Name:CAMPBELL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:2025 US ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143
Mailing Address - Country:US
Mailing Address - Phone:518-756-5200
Mailing Address - Fax:
Practice Address - Street 1:2025 US ROUTE 9W
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143
Practice Address - Country:US
Practice Address - Phone:518-756-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098542104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker