Provider Demographics
NPI:1720865793
Name:CAMPBELL, TATIANA D (LPC)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:D
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5908 GETWELL RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7317
Practice Address - Country:US
Practice Address - Phone:662-536-4646
Practice Address - Fax:662-536-4443
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012355101YM0800X
MS3056101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health