Provider Demographics
NPI:1265680847
Name:CAMPBELL, MICHELLE ROSE (MSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E. BURNSIDE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-239-8406
Practice Address - Street 1:1027 E. BURNSIDE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:503-239-8406
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125001555174400000X
1041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health