Provider Demographics
NPI:1710761176
Name:CAMPBELL, KRISTAL MAE
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:MAE
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 1:25140 STEINBECK AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25140 STEINBECK AVE UNIT B
Practice Address - Street 2:
Practice Address - City:STEVENSON RANCH
Practice Address - State:CA
Practice Address - Zip Code:91381-1297
Practice Address - Country:US
Practice Address - Phone:818-859-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health