Provider Demographics
NPI:1790350072
Name:CAMPBELL, LAURA JANNETTE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JANNETTE
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 1:809 COURTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4833
Mailing Address - Country:US
Mailing Address - Phone:847-830-1076
Mailing Address - Fax:
Practice Address - Street 1:3000 DUNDEE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2424
Practice Address - Country:US
Practice Address - Phone:847-499-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490230771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical