Provider Demographics
NPI:1922331206
Name:CAMPBELL, MARY MARGARET (LADAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 GUSDORF RD STE E
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5227
Mailing Address - Country:US
Mailing Address - Phone:575-737-9042
Mailing Address - Fax:575-751-3557
Practice Address - Street 1:1335 GUSDORF RD STE E
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5227
Practice Address - Country:US
Practice Address - Phone:575-737-9042
Practice Address - Fax:575-751-3557
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0095301101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)