Provider Demographics
NPI:1134559222
Name:CAMPBELL, LUTHER
Entity type:Individual
Prefix:
First Name:LUTHER
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N WAUKEGAN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-1694
Mailing Address - Country:US
Mailing Address - Phone:224-544-9167
Mailing Address - Fax:
Practice Address - Street 1:100 N WAUKEGAN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044
Practice Address - Country:US
Practice Address - Phone:224-544-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4229101YP2500X
IL180.011306101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional