Provider Demographics
NPI:1891800777
Name:CAMPBELL, MARITA T (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:MARITA
Middle Name:T
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209
Mailing Address - Country:US
Mailing Address - Phone:716-886-7304
Mailing Address - Fax:716-886-7398
Practice Address - Street 1:406 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209
Practice Address - Country:US
Practice Address - Phone:716-886-7304
Practice Address - Fax:716-886-7398
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03806211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01573486Medicaid
NY00520127001OtherINDEPENDENT HEALTH
NY00523251001OtherBLUE CROSS
7487947002OtherVALUE OPTIONS
NY00020127001OtherUNIVERA
NY040426030939OtherFIDELLS
7487947002OtherVALUE OPTIONS