Provider Demographics
NPI:1942850532
Name:CAMPBELL, MARSAIAH R
Entity Type:Individual
Prefix:
First Name:MARSAIAH
Middle Name:R
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 1:2100 LAKE WASHINGTON BLVD N APT H304
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1461
Mailing Address - Country:US
Mailing Address - Phone:206-407-9205
Mailing Address - Fax:
Practice Address - Street 1:2100 LAKE WASHINGTON BLVD N APT H304
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-1461
Practice Address - Country:US
Practice Address - Phone:206-407-9205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60978446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician