Provider Demographics
NPI:1154833499
Name:STALLWORTH, ALTHELDA CAMPBELL
Entity Type:Individual
Prefix:
First Name:ALTHELDA
Middle Name:CAMPBELL
Last Name:STALLWORTH
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 1:2338 FERNWOOD LOOP W
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-7562
Mailing Address - Country:US
Mailing Address - Phone:251-209-1894
Mailing Address - Fax:251-459-0991
Practice Address - Street 1:3220 MEADOW LN
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-4638
Practice Address - Country:US
Practice Address - Phone:251-209-1894
Practice Address - Fax:251-459-0991
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities