Provider Demographics
NPI:1033707641
Name:CAMPBELL, DUSTAN YATES
Entity Type:Individual
Prefix:
First Name:DUSTAN
Middle Name:YATES
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S CLAY ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3132
Mailing Address - Country:US
Mailing Address - Phone:314-712-3411
Mailing Address - Fax:
Practice Address - Street 1:1500 W ASHLAND ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-1710
Practice Address - Country:US
Practice Address - Phone:314-712-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020040530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty