Provider Demographics
NPI:1689331977
Name:CAMPBELL, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
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 1:12689 STONERIDGE LN APT 104
Mailing Address - Street 2:
Mailing Address - City:SOUTH ROCKWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48179-9545
Mailing Address - Country:US
Mailing Address - Phone:734-778-0809
Mailing Address - Fax:
Practice Address - Street 1:19291 NORTHLINE RD # 6
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2220
Practice Address - Country:US
Practice Address - Phone:734-287-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801110427104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker