Provider Demographics
NPI:1720351083
Name:CAMPBELL, STACY FAYE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:FAYE
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 1:11905 ARBOR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2970
Mailing Address - Country:US
Mailing Address - Phone:402-594-4410
Mailing Address - Fax:402-330-8873
Practice Address - Street 1:1941 S 42ND ST
Practice Address - Street 2:SUITE 328
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2939
Practice Address - Country:US
Practice Address - Phone:402-614-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2247101YM0800X
NE1331101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health