Provider Demographics
NPI:1205292299
Name:CAMPBELL, MARI (PTA)
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 BROWN HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45144-9407
Mailing Address - Country:US
Mailing Address - Phone:937-779-7518
Mailing Address - Fax:
Practice Address - Street 1:479 TUCKER DRIVE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056
Practice Address - Country:US
Practice Address - Phone:855-584-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01099225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant