Provider Demographics
NPI:1720836927
Name:CAMPBELL, SHAVELLE ASHLEY
Entity Type:Individual
Prefix:
First Name:SHAVELLE
Middle Name:ASHLEY
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 1:77 HARTLAND ST STE 108
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3259
Mailing Address - Country:US
Mailing Address - Phone:860-362-0225
Mailing Address - Fax:
Practice Address - Street 1:144 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3239
Practice Address - Country:US
Practice Address - Phone:959-258-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst