Provider Demographics
NPI:1609274224
Name:CAMPBELL, LATANYA
Entity Type:Individual
Prefix:MRS
First Name:LATANYA
Middle Name:
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 1:4249 N COMMERCE ST
Mailing Address - Street 2:UNIT 2096
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-1181
Mailing Address - Country:US
Mailing Address - Phone:702-717-8228
Mailing Address - Fax:
Practice Address - Street 1:7455 ARROYO CROSSING PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-4085
Practice Address - Country:US
Practice Address - Phone:702-764-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9999999Medicaid