Provider Demographics
NPI:1134661077
Name:CAMPBELL, STEPHANIE (CAC-AD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 CRAIN HWY N STE 1B
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-9306
Mailing Address - Country:US
Mailing Address - Phone:410-766-6624
Mailing Address - Fax:410-766-0240
Practice Address - Street 1:1412 CRAIN HWY N STE 1B
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-9306
Practice Address - Country:US
Practice Address - Phone:410-766-6624
Practice Address - Fax:410-766-0240
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0283101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)