Provider Demographics
NPI:1417738048
Name:CAMPBELL, EDWIN B JR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:B
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 S MONTANA CIR
Mailing Address - Street 2:
Mailing Address - City:LABELLE
Mailing Address - State:FL
Mailing Address - Zip Code:33935-5356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2007 S MONTANA CIR
Practice Address - Street 2:
Practice Address - City:LABELLE
Practice Address - State:FL
Practice Address - Zip Code:33935-5356
Practice Address - Country:US
Practice Address - Phone:305-528-2293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-288551106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician