Provider Demographics
NPI:1033848098
Name:CAMPBELL, KAITLIN NICOLE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:NICOLE
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 1:26217 FM 139
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75973-3784
Mailing Address - Country:US
Mailing Address - Phone:936-488-9090
Mailing Address - Fax:
Practice Address - Street 1:10317 US HIGHWAY 259
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-0815
Practice Address - Country:US
Practice Address - Phone:936-552-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119543235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist