Provider Demographics
NPI:1922410406
Name:CAMPBELL, SHEREE
Entity Type:Individual
Prefix:
First Name:SHEREE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHEREE
Other - Middle Name:ANN
Other - Last Name:MEYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40A CORTO LN
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2460
Mailing Address - Country:US
Mailing Address - Phone:650-799-5236
Mailing Address - Fax:
Practice Address - Street 1:40A CORTO LN
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:CA
Practice Address - Zip Code:94062
Practice Address - Country:US
Practice Address - Phone:650-799-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2018-07-19
Deactivation Date:2014-06-20
Deactivation Code:
Reactivation Date:2018-07-10
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY28821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist