Provider Demographics
NPI:1700194016
Name:CAMPBELL, JOHN C
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
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 1:150 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-1812
Mailing Address - Country:US
Mailing Address - Phone:207-582-3402
Mailing Address - Fax:
Practice Address - Street 1:150 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:ME
Practice Address - Zip Code:04345-1812
Practice Address - Country:US
Practice Address - Phone:207-582-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC72681041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool