Provider Demographics
NPI:1205401833
Name:CAMPBELL, MARY LYNN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:CAMPBELL
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 1:1532 VANDENBERG DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-7639
Mailing Address - Country:US
Mailing Address - Phone:270-985-3722
Mailing Address - Fax:
Practice Address - Street 1:1532 VANDENBERG DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-7639
Practice Address - Country:US
Practice Address - Phone:127-098-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician