Provider Demographics
NPI:1164799557
Name:CAMPBELL, GREGGORY FITZGERALD SR
Entity Type:Individual
Prefix:MR
First Name:GREGGORY
Middle Name:FITZGERALD
Last Name:CAMPBELL
Suffix:SR
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 1:17760 NW 67TH AVE APT 801
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5876
Mailing Address - Country:US
Mailing Address - Phone:786-258-1900
Mailing Address - Fax:
Practice Address - Street 1:2450 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1424
Practice Address - Country:US
Practice Address - Phone:954-202-9334
Practice Address - Fax:954-202-7912
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL956497101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool