Provider Demographics
NPI:1467691907
Name:CAMPBELL, WILLIE LARRY (LMSW)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:LARRY
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:W.
Other - Middle Name:LARRY
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:11266 E INDIAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-9560
Mailing Address - Country:US
Mailing Address - Phone:248-202-7919
Mailing Address - Fax:
Practice Address - Street 1:3800 LAKELAND LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-1327
Practice Address - Country:US
Practice Address - Phone:248-973-3660
Practice Address - Fax:248-973-3662
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010354361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical