Provider Demographics
NPI:1245638956
Name:CAMPBELL, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
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 1:315 DR. MARTIN LUTHER KING DR.
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104
Mailing Address - Country:US
Mailing Address - Phone:901-827-0571
Mailing Address - Fax:800-594-5117
Practice Address - Street 1:315 S SOMERVILLE ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3352
Practice Address - Country:US
Practice Address - Phone:901-827-0571
Practice Address - Fax:500-594-5717
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000015350101YA0400X
TN1000000014991101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ009263Medicaid