Provider Demographics
NPI:1093221350
Name:CAMPBELL, ELIZABETH BROOKE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BROOKE
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 1:4805 MONTGOMERY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2280
Mailing Address - Country:US
Mailing Address - Phone:513-961-5558
Mailing Address - Fax:513-961-1912
Practice Address - Street 1:320 THOMAS MORE PKWY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-341-4266
Practice Address - Fax:859-344-5076
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY277928103T00000X, 103G00000X
MI6301019071103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100846950Medicaid