Provider Demographics
NPI:1023355039
Name:CAMPBELL-MUCK, MARILYN (LMHC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CAMPBELL-MUCK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:WAITE
Other - Last Name:FACKLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1600 SARNO RD
Mailing Address - Street 2:SUITE 119J
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4938
Mailing Address - Country:US
Mailing Address - Phone:321-243-0262
Mailing Address - Fax:
Practice Address - Street 1:1600 SARNO RD
Practice Address - Street 2:SUITE 119J
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-243-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8329101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health