Provider Demographics
NPI:1619253929
Name:CAMPBELL, KAITLIN P (LCSW)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:P
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10125 RIDGEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-2749
Mailing Address - Country:US
Mailing Address - Phone:512-560-0464
Mailing Address - Fax:
Practice Address - Street 1:12801 N CENTRAL EXPY STE 510
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1716
Practice Address - Country:US
Practice Address - Phone:512-560-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX409961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX78703Medicaid