Provider Demographics
NPI:1992217897
Name:CAMPBELL, CARLA D (CDCA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 E EMMITT AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1337
Mailing Address - Country:US
Mailing Address - Phone:740-947-6727
Mailing Address - Fax:
Practice Address - Street 1:217 E EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1337
Practice Address - Country:US
Practice Address - Phone:740-947-6727
Practice Address - Fax:740-835-8723
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847236Medicaid