Provider Demographics
NPI:1437562428
Name:CAMPBELL, BERNADETTE T (LMP)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:T
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-0621
Mailing Address - Country:US
Mailing Address - Phone:360-635-3665
Mailing Address - Fax:
Practice Address - Street 1:139 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648-6648
Practice Address - Country:US
Practice Address - Phone:360-635-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60169906225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist