Provider Demographics
NPI:1568079010
Name:CAMPBELL, PAUL ANTHONY
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 CALVERT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1407
Mailing Address - Country:US
Mailing Address - Phone:313-938-8372
Mailing Address - Fax:
Practice Address - Street 1:10 PETERBORO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2722
Practice Address - Country:US
Practice Address - Phone:313-831-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801107232104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker