Provider Demographics
NPI:1811210495
Name:CAMPBELL WALLACE, JUDITH MARGARET (MS)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:MARGARET
Last Name:CAMPBELL WALLACE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:MARGARET
Other - Middle Name:CAMPBELL
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:301 S. PERIMETER PARK DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4143
Mailing Address - Country:US
Mailing Address - Phone:865-525-0391
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:423-509-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health