Provider Demographics
NPI:1558404780
Name:CAMPBELL, STEPHEN (ATC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HERRINGTON RD
Mailing Address - Street 2:APT. #22308
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2280
Mailing Address - Country:US
Mailing Address - Phone:678-977-8482
Mailing Address - Fax:
Practice Address - Street 1:1400 HERRINGTON RD
Practice Address - Street 2:APT. #22308
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2280
Practice Address - Country:US
Practice Address - Phone:678-977-8482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0013712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer