Provider Demographics
NPI:1265849822
Name:CAMPBELL, SHUSHAN (PHD, LCP)
Entity Type:Individual
Prefix:DR
First Name:SHUSHAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10521 ROSEHAVEN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2876
Mailing Address - Country:US
Mailing Address - Phone:703-352-3822
Mailing Address - Fax:
Practice Address - Street 1:10521 ROSEHAVEN ST STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2877
Practice Address - Country:US
Practice Address - Phone:703-352-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2020-04-08
Deactivation Date:2019-03-27
Deactivation Code:
Reactivation Date:2020-04-08
Provider Licenses
StateLicense IDTaxonomies
VA0810006451103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1265849822OtherSOLE PROPRIETOR