Provider Demographics
NPI:1023494770
Name:CAMPBELL, DOMONIQUE (LLMSW)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:
Practice Address - Street 1:13305 REECK CT
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3197
Practice Address - Country:US
Practice Address - Phone:734-225-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011030681041C0700X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other