Provider Demographics
NPI:1780225987
Name:CAMPBELL, AMY (LSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 LEE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1255
Mailing Address - Country:US
Mailing Address - Phone:216-600-5194
Mailing Address - Fax:
Practice Address - Street 1:2490 LEE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44118-1255
Practice Address - Country:US
Practice Address - Phone:216-600-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1500640104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker