Provider Demographics
NPI:1982316915
Name:CAMPBELL, ELVIN EMANUEL (BA, BSW, AAS, PRSS)
Entity Type:Individual
Prefix:
First Name:ELVIN
Middle Name:EMANUEL
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:BA, BSW, AAS, PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 KANAWHA BLVD W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-2533
Mailing Address - Country:US
Mailing Address - Phone:304-610-9964
Mailing Address - Fax:304-768-7647
Practice Address - Street 1:1514 KANAWHA BLVD W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2533
Practice Address - Country:US
Practice Address - Phone:304-610-9964
Practice Address - Fax:304-768-7647
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV175T00000XMedicaid