Provider Demographics
NPI:1649332644
Name:GREEN-CAMPBELL, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GREEN-CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 RAINWATER RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-5700
Mailing Address - Country:US
Mailing Address - Phone:804-869-1096
Mailing Address - Fax:
Practice Address - Street 1:224 CENTRAL LN
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4423
Practice Address - Country:US
Practice Address - Phone:804-869-1096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009467101YP2500X
VA0701003962101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional