Provider Demographics
NPI:1881881654
Name:CAMPBELL, MICHELLE (MT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 JEFFERSON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263
Mailing Address - Country:US
Mailing Address - Phone:770-683-9105
Mailing Address - Fax:770-683-9107
Practice Address - Street 1:197 JEFFERSON PARKWAY
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263
Practice Address - Country:US
Practice Address - Phone:770-683-9105
Practice Address - Fax:770-683-9107
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002959225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT002959OtherMASSAGE THERAPIST