Provider Demographics
NPI:1528182771
Name:CAMPBELL, CAROLYN (MSW,ACSW,BCD,LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW,ACSW,BCD,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 W IRVING PARK RD APT E8
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3159
Mailing Address - Country:US
Mailing Address - Phone:773-472-8725
Mailing Address - Fax:773-472-1993
Practice Address - Street 1:112 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2014
Practice Address - Country:US
Practice Address - Phone:312-787-2729
Practice Address - Fax:312-943-4459
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02215636OtherBCBS PROVIDER NUMBER
ILK15263Medicare ID - Type Unspecified