Provider Demographics
NPI:1386219764
Name:CAMPBELL, CARLA DIANE
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:DIANE
Last Name:CAMPBELL
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 1:13951 W BATTENBERG CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1275
Mailing Address - Country:US
Mailing Address - Phone:208-908-9257
Mailing Address - Fax:
Practice Address - Street 1:13951 W BATTENBERG CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1275
Practice Address - Country:US
Practice Address - Phone:208-908-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician