Provider Demographics
NPI:1659833788
Name:CAMPBELL, HOLLIE FAY
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:FAY
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 1:13728 W CAREFREE DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8655
Mailing Address - Country:US
Mailing Address - Phone:815-955-8725
Mailing Address - Fax:
Practice Address - Street 1:13728 W CAREFREE DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8655
Practice Address - Country:US
Practice Address - Phone:708-507-5543
Practice Address - Fax:708-966-4244
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011291101YP2500X
IL180015266101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty