Provider Demographics
NPI:1841848587
Name:CAMPBELL, BENJAMIN MICHAEL (LLP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23767 BATTELLE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1422
Mailing Address - Country:US
Mailing Address - Phone:310-745-9834
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST STE 204
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3803
Practice Address - Country:US
Practice Address - Phone:248-504-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018072103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist