Provider Demographics
NPI:1912394008
Name:CAMPBELL, ELLYETTE
Entity Type:Individual
Prefix:
First Name:ELLYETTE
Middle Name:
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 1:2311 IVY HILL WAY APT 824
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4316
Mailing Address - Country:US
Mailing Address - Phone:949-422-7943
Mailing Address - Fax:925-743-9614
Practice Address - Street 1:760 SAN RAMON VALLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4057
Practice Address - Country:US
Practice Address - Phone:925-743-8905
Practice Address - Fax:925-743-9614
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3140225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand