Provider Demographics
NPI:1598727729
Name:CAMPAGNOLA, SUSAN OK (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:OK
Last Name:CAMPAGNOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9228 GEORGE WASHINGTON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-4162
Mailing Address - Country:US
Mailing Address - Phone:804-693-5068
Mailing Address - Fax:804-693-7407
Practice Address - Street 1:414 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:VA
Practice Address - Zip Code:22572-4291
Practice Address - Country:US
Practice Address - Phone:804-333-3671
Practice Address - Fax:804-333-3657
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904004978104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA114431OtherHEALTHKEEPERS
VA114431OtherANTHEM
VA331724OtherTRICARE
VA7093521OtherAETNA
VAO80431MMedicaid
VA114431Medicaid
VAO80431MOtherSOUTHERN HEALTH
VAO80431MMedicaid
VA001087M13Medicare ID - Type UnspecifiedMEDICARE