Provider Demographics
NPI:1356869226
Name:CAMPBELL, MARK THOMAS
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:THOMAS
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 1:7120 N MARKS AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0268
Mailing Address - Country:US
Mailing Address - Phone:559-476-2166
Mailing Address - Fax:884-563-6035
Practice Address - Street 1:7120 N MARKS AVE STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-0268
Practice Address - Country:US
Practice Address - Phone:559-439-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health