Provider Demographics
NPI:1194846519
Name:CAMPBELL, CORRIN L (COTA)
Entity Type:Individual
Prefix:
First Name:CORRIN
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 EDGEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-2106
Mailing Address - Country:US
Mailing Address - Phone:860-621-0598
Mailing Address - Fax:
Practice Address - Street 1:45 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3214
Practice Address - Country:US
Practice Address - Phone:860-378-1234
Practice Address - Fax:860-378-1160
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000797224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant