Provider Demographics
NPI:1720394661
Name:CAMPBELL, DOREEN T (LISW)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:T
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 237
Mailing Address - Street 2:
Mailing Address - City:EL RITO
Mailing Address - State:NM
Mailing Address - Zip Code:87530
Mailing Address - Country:US
Mailing Address - Phone:575-581-4728
Mailing Address - Fax:575-581-0030
Practice Address - Street 1:1574 STATE ROAD 502
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-2697
Practice Address - Country:US
Practice Address - Phone:505-455-4026
Practice Address - Fax:505-455-4038
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-083961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid