Provider Demographics
NPI:1952166969
Name:CAMPBELL, KENYA SHANAE
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:SHANAE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 W HIGHLAND AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5059
Mailing Address - Country:US
Mailing Address - Phone:224-477-0643
Mailing Address - Fax:
Practice Address - Street 1:1845 GRANDSTAND PL
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-6603
Practice Address - Country:US
Practice Address - Phone:847-695-0484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician