Provider Demographics
NPI:1922057330
Name:CAMPBELL, LAURIE DENISE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:DENISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2404 S LOCUST ST
Mailing Address - Street 2:STE 5
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5789
Mailing Address - Country:US
Mailing Address - Phone:505-521-4188
Mailing Address - Fax:505-521-3668
Practice Address - Street 1:2404 S LOCUST ST
Practice Address - Street 2:STE 5
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5789
Practice Address - Country:US
Practice Address - Phone:505-521-4188
Practice Address - Fax:505-521-3668
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00079819Medicaid