Provider Demographics
NPI:1235258559
Name:CAMPBELL, SUSAN KENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KENT
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 GREENWOOD CLFS
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2821
Mailing Address - Country:US
Mailing Address - Phone:704-736-6577
Mailing Address - Fax:
Practice Address - Street 1:1132 GREENWOOD CLFS
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2821
Practice Address - Country:US
Practice Address - Phone:704-376-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4796103T00000X
GAPSY002216103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000913657AMedicaid