Provider Demographics
NPI:1558656207
Name:CAMPBELL, LAKISCHA SIMONE
Entity Type:Individual
Prefix:
First Name:LAKISCHA
Middle Name:SIMONE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 ARLINGTON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-1966
Mailing Address - Country:US
Mailing Address - Phone:951-352-3943
Mailing Address - Fax:
Practice Address - Street 1:6711 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-1955
Practice Address - Country:US
Practice Address - Phone:951-352-3943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94022231103TC0700X
CAIMF75218106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical