Provider Demographics
NPI:1669257093
Name:CAMPBELL, ANGELA M
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name: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 1:12805 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9546
Mailing Address - Country:US
Mailing Address - Phone:901-229-3093
Mailing Address - Fax:
Practice Address - Street 1:12805 ARBOR DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-9546
Practice Address - Country:US
Practice Address - Phone:901-229-3093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN141701041C0700X
MSM100411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical