Provider Demographics
NPI:1710584321
Name:CAMPBELL, ALYSSA DANIELLE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:DANIELLE
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 1:1405 SAN CARLOS RD SW APT 5
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1060
Mailing Address - Country:US
Mailing Address - Phone:505-514-1160
Mailing Address - Fax:
Practice Address - Street 1:1405 SAN CARLOS RD SW APT 5
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1060
Practice Address - Country:US
Practice Address - Phone:505-514-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician