Provider Demographics
NPI:1760500276
Name:CAMPBELL, MICHELLE ANGELA (MA, LMHC, BCBA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANGELA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MA, LMHC, BCBA
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ANGELA
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10940 LIVERPOOL ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5730
Mailing Address - Country:US
Mailing Address - Phone:718-297-9825
Mailing Address - Fax:
Practice Address - Street 1:10940 LIVERPOOL ST
Practice Address - Street 2:SUITE #1
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5730
Practice Address - Country:US
Practice Address - Phone:718-297-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-11-8757103K00000X
NY003272-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst