Provider Demographics
NPI:1336314582
Name:CAMPBELL, DENNIS RAY (MS)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RAY
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:573-582-1212
Practice Address - Street 1:321 WEST PROMENADE
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:573-582-1212
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01380103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist