Provider Demographics
NPI:1346961844
Name:MCCAMPBELL, CHANEL
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:MCCAMPBELL
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 1:14201 KENTWOOD BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2472
Mailing Address - Country:US
Mailing Address - Phone:760-437-2676
Mailing Address - Fax:760-267-1909
Practice Address - Street 1:14201 KENTWOOD BLVD STE 2
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2472
Practice Address - Country:US
Practice Address - Phone:760-437-2676
Practice Address - Fax:760-267-1909
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115841106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA882411754Medicaid