Provider Demographics
NPI:1164564175
Name:CAMPBELL-WILLIAMS, ANDREA DENICE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DENICE
Last Name:CAMPBELL-WILLIAMS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4491 BESSIE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-2707
Mailing Address - Country:US
Mailing Address - Phone:314-389-4820
Mailing Address - Fax:
Practice Address - Street 1:4491 BESSIE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-2707
Practice Address - Country:US
Practice Address - Phone:314-660-1690
Practice Address - Fax:314-389-4820
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO466958808Medicaid