Provider Demographics
NPI:1962843250
Name:CAMPBELL, JOHN GLENN (LCDCIII)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GLENN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5377 PALM LANE
Mailing Address - Street 2:
Mailing Address - City:CLEVES
Mailing Address - State:OH
Mailing Address - Zip Code:45002-9363
Mailing Address - Country:US
Mailing Address - Phone:513-227-4106
Mailing Address - Fax:
Practice Address - Street 1:6460 HARRISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7958
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)