Provider Demographics
NPI:1619400173
Name:CAMPBELL, DAMIEN
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E MAIN ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1318
Mailing Address - Country:US
Mailing Address - Phone:859-233-0444
Mailing Address - Fax:
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1318
Practice Address - Country:US
Practice Address - Phone:859-233-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid