Provider Demographics
NPI:1952678799
Name:CAMPBELL, TERESA A
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
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 1:307 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65063-5417
Mailing Address - Country:US
Mailing Address - Phone:573-491-3700
Mailing Address - Fax:573-491-3772
Practice Address - Street 1:307 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:65063-5417
Practice Address - Country:US
Practice Address - Phone:573-491-3700
Practice Address - Fax:573-491-3772
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist