Provider Demographics
NPI:1598095499
Name:CAMPBELL, DIANA L
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:L
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 1:5412 N CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1223
Mailing Address - Country:US
Mailing Address - Phone:773-368-9619
Mailing Address - Fax:
Practice Address - Street 1:5412 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1223
Practice Address - Country:US
Practice Address - Phone:773-368-9619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0171311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical