Provider Demographics
NPI:1053815589
Name:CAMPBELL, CARLETON THOMAS
Entity Type:Individual
Prefix:
First Name:CARLETON
Middle Name:THOMAS
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 1:964 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-9363
Mailing Address - Country:US
Mailing Address - Phone:330-424-1468
Mailing Address - Fax:330-424-9844
Practice Address - Street 1:1010 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-1846
Practice Address - Country:US
Practice Address - Phone:330-424-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165351101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.165351OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD