Provider Demographics
NPI:1972836872
Name:CAMPBELL, MIRANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 KINGS POINT DR
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5925
Mailing Address - Country:US
Mailing Address - Phone:714-791-0434
Mailing Address - Fax:
Practice Address - Street 1:2346 KINGS POINT DR
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-5925
Practice Address - Country:US
Practice Address - Phone:714-791-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0049771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical