Provider Demographics
NPI:1871024703
Name:CAMPBELL, CANDICE LEAH (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:LEAH
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 W VILLAGE PL SE
Mailing Address - Street 2:#4309
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-9204
Mailing Address - Country:US
Mailing Address - Phone:205-447-2844
Mailing Address - Fax:
Practice Address - Street 1:4600 W VILLAGE PL SE
Practice Address - Street 2:#4309
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-9204
Practice Address - Country:US
Practice Address - Phone:205-447-2844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009468235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist