Provider Demographics
NPI:1235212028
Name:CAMPBELL, MICHAEL E (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 PROSPECTOR TRAIL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548
Mailing Address - Country:US
Mailing Address - Phone:254-699-1512
Mailing Address - Fax:254-690-1532
Practice Address - Street 1:880 PROSPECTOR TRAIL
Practice Address - Street 2:SUITE 100
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548
Practice Address - Country:US
Practice Address - Phone:254-690-1512
Practice Address - Fax:254-690-1532
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21603103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0354581-01Medicaid
TX0354581-01Medicaid