Provider Demographics
NPI:1477378362
Name:CAMPBELL, DORETH (OTR)
Entity type:Individual
Prefix:
First Name:DORETH
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16907 HIMLEY DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16907 HIMLEY DR
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-5002
Practice Address - Country:US
Practice Address - Phone:832-776-9375
Practice Address - Fax:888-533-3786
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110512225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty