Provider Demographics
NPI:1528012135
Name:CAMPBELL, ALISE V (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ALISE
Middle Name:V
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 1:2330 VARTAN WAY
Mailing Address - Street 2:SUITE #150
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-9763
Mailing Address - Country:US
Mailing Address - Phone:717-421-3135
Mailing Address - Fax:
Practice Address - Street 1:2330 VARTAN WAY
Practice Address - Street 2:SUITE #150
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9763
Practice Address - Country:US
Practice Address - Phone:717-421-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0155061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021393700001Medicaid
PA109207Medicare PIN