Provider Demographics
NPI:1467229757
Name:CAMPBELL, MAIA (LCSW)
Entity Type:Individual
Prefix:
First Name:MAIA
Middle Name:
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 1:317 E COURT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4245
Mailing Address - Country:US
Mailing Address - Phone:607-288-3270
Mailing Address - Fax:
Practice Address - Street 1:317 E COURT ST APT 3
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4245
Practice Address - Country:US
Practice Address - Phone:607-288-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0966021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical