Provider Demographics
NPI:1336152081
Name:CAMPBELL, MARY ELLEN (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:CHINCHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:36 HAWTHORNE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7114
Mailing Address - Country:US
Mailing Address - Phone:541-776-2333
Mailing Address - Fax:541-776-2495
Practice Address - Street 1:158 W MAIN
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524
Practice Address - Country:US
Practice Address - Phone:541-830-0914
Practice Address - Fax:541-830-0923
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0065781225100000X
OR6716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist