Provider Demographics
NPI:1417153214
Name:CAMPBELL, TERESA LEA (COTA L)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LEA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:COTA L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 DUNWICH DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3216
Mailing Address - Country:US
Mailing Address - Phone:816-792-1168
Mailing Address - Fax:
Practice Address - Street 1:10300 W 103RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-2642
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004876174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO004876OtherMISSOURI LICENSE