Provider Demographics
NPI:1700951910
Name:CAMBURN, THERESA ANN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:CAMBURN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093
Mailing Address - Country:US
Mailing Address - Phone:269-273-5000
Mailing Address - Fax:269-273-9456
Practice Address - Street 1:210 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093
Practice Address - Country:US
Practice Address - Phone:269-273-5000
Practice Address - Fax:269-273-9456
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010855081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicare ID - Type Unspecified