Provider Demographics
NPI:1831364777
Name:CAMPBELL, DOLORES L (MS)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4405
Mailing Address - Country:US
Mailing Address - Phone:631-473-7045
Mailing Address - Fax:
Practice Address - Street 1:1 OTSEGO ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-4405
Practice Address - Country:US
Practice Address - Phone:631-473-7045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1206231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02100241Medicaid