Provider Demographics
NPI:1598883829
Name:CAMPBELL-GLASCO, KIMBERLIE
Entity Type:Individual
Prefix:
First Name:KIMBERLIE
Middle Name:
Last Name:CAMPBELL-GLASCO
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 1:1169 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6075
Mailing Address - Country:US
Mailing Address - Phone:248-969-4977
Mailing Address - Fax:
Practice Address - Street 1:2633 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:ORION
Practice Address - State:MI
Practice Address - Zip Code:48360
Practice Address - Country:US
Practice Address - Phone:248-393-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008053101YM0800X
103T00000X, 101Y00000X
MI6301012072103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical