Provider Demographics
NPI:1144794884
Name:CAMPBELL, MARK V
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:V
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 1:4380 W 12TH ST STE 3A
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3028
Mailing Address - Country:US
Mailing Address - Phone:814-392-3888
Mailing Address - Fax:814-833-3019
Practice Address - Street 1:4380 W 12TH ST STE 3A
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3028
Practice Address - Country:US
Practice Address - Phone:814-657-6295
Practice Address - Fax:814-833-3019
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011026101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional