Provider Demographics
NPI:1457453110
Name:CAMPBELL, MARY ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MONTAUK AVE
Mailing Address - Street 2:P.O. BOX 390
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4906
Mailing Address - Country:US
Mailing Address - Phone:860-271-4700
Mailing Address - Fax:860-271-4797
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-271-4700
Practice Address - Fax:860-271-4797
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061363844OtherTAX ID
CT140889OtherVALUE OPTIONS
CT004254976OtherCTBP
CT800001896Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER