Provider Demographics
NPI:1417453010
Name:CAMPBELL, MICA (PTA-L)
Entity Type:Individual
Prefix:MRS
First Name:MICA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14211 WHITE CREEK AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-8168
Mailing Address - Country:US
Mailing Address - Phone:616-252-6330
Mailing Address - Fax:616-252-6366
Practice Address - Street 1:14211 WHITE CREEK AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8168
Practice Address - Country:US
Practice Address - Phone:616-252-6330
Practice Address - Fax:616-252-6366
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001183225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant