Provider Demographics
NPI:1841496270
Name:CAMPBELL, MATTHEW GIBSON (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:GIBSON
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WHITNEY GATE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-361-6858
Mailing Address - Fax:631-224-4992
Practice Address - Street 1:22 LAWRENCE AVE STE 304
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3619
Practice Address - Country:US
Practice Address - Phone:631-361-6858
Practice Address - Fax:631-224-4992
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9479103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V58032Medicare ID - Type Unspecified