Provider Demographics
NPI:1831471036
Name:CAMPBELL, HEATHER WALLACE (LCPC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:WALLACE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E WATER ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-1155
Mailing Address - Country:US
Mailing Address - Phone:410-739-9068
Mailing Address - Fax:410-648-6862
Practice Address - Street 1:205 E WATER ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-1155
Practice Address - Country:US
Practice Address - Phone:410-739-9068
Practice Address - Fax:410-648-6862
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1647101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional