Provider Demographics
NPI:1609245679
Name:CAMPBELL, MARY ROSE (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ROSE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1231
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929
Mailing Address - Country:US
Mailing Address - Phone:907-874-2373
Mailing Address - Fax:907-874-2576
Practice Address - Street 1:333 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929-1231
Practice Address - Country:US
Practice Address - Phone:907-874-2373
Practice Address - Fax:907-874-2576
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor