Provider Demographics
NPI:1639305998
Name:CAMPBELL, ALEX R
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:R
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, BCBA, MFT
Mailing Address - Street 1:185 DRAKEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4681
Mailing Address - Country:US
Mailing Address - Phone:415-971-1186
Mailing Address - Fax:415-366-1685
Practice Address - Street 1:264 ARLINGTON AVE STE 2
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1416
Practice Address - Country:US
Practice Address - Phone:415-971-1186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1084718103K00000X
CAMFC30244106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist