Provider Demographics
NPI:1417061789
Name:CAMPBELL, SUSAN S (PHD MFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHD MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 S 100 W STE 203
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6071
Mailing Address - Country:US
Mailing Address - Phone:435-752-1976
Mailing Address - Fax:435-755-6707
Practice Address - Street 1:965 S 100 W STE 203
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6071
Practice Address - Country:US
Practice Address - Phone:435-752-1976
Practice Address - Fax:435-755-6707
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274716-3902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health