Provider Demographics
NPI:1700103116
Name:CAMPBELL, MITCHELL DALE (AUD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:DALE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2793
Mailing Address - Country:US
Mailing Address - Phone:502-515-3320
Mailing Address - Fax:502-515-3325
Practice Address - Street 1:117 E KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2793
Practice Address - Country:US
Practice Address - Phone:502-584-3573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-24
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0519231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist