Provider Demographics
NPI:1568185569
Name:CAMPBELL, KATHRYN LILLY
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LILLY
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 1:61 WENONAH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-2719
Mailing Address - Country:US
Mailing Address - Phone:973-879-8815
Mailing Address - Fax:
Practice Address - Street 1:540 ROUTE 22
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2405
Practice Address - Country:US
Practice Address - Phone:908-722-1881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL068520001041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical