Provider Demographics
NPI:1790277234
Name:CAMPBELL, LAURA IVY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:IVY
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 NURSERY RD
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-5128
Mailing Address - Country:US
Mailing Address - Phone:570-394-8907
Mailing Address - Fax:
Practice Address - Street 1:16 WOODBINE LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-8029
Practice Address - Country:US
Practice Address - Phone:570-271-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0003832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE