Provider Demographics
NPI:1073128492
Name:CAMPBELL, SAMUEL JR
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CAMPBELL
Suffix:JR
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 1:9556 LANGDON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-2103
Mailing Address - Country:US
Mailing Address - Phone:310-930-0199
Mailing Address - Fax:
Practice Address - Street 1:4200 CRESCENT ROCK LN
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-2860
Practice Address - Country:US
Practice Address - Phone:310-930-0199
Practice Address - Fax:818-475-1914
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA157806092322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children