Provider Demographics
NPI:1093991069
Name:CAMPBELL, LAQUANITA SHANEL
Entity Type:Individual
Prefix:
First Name:LAQUANITA
Middle Name:SHANEL
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 1:6814 STABLETON LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77049-2054
Mailing Address - Country:US
Mailing Address - Phone:713-548-7438
Mailing Address - Fax:
Practice Address - Street 1:6814 STABLETON LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-2054
Practice Address - Country:US
Practice Address - Phone:713-548-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X, 322D00000X, 320700000X, 323P00000X, 3245S0500X
TX210151164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No164X00000XNursing Service ProvidersLicensed Vocational Nurse