Basic Information
Provider Information
NPI: 1003006594
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CAMPBELL
FirstName: FERN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 808 N 8TH AVE
Address2:  
City: POCATELLO
State: ID
PostalCode: 832015718
CountryCode: US
TelephoneNumber: 2082361600
FaxNumber: 2082366695
Practice Location
Address1: 2055 GARRETT WAY
Address2: SUITE 1
City: POCATELLO
State: ID
PostalCode: 832015100
CountryCode: US
TelephoneNumber: 2082361600
FaxNumber: 2082366695
Other Information
ProviderEnumerationDate: 07/31/2007
LastUpdateDate: 07/31/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000XLSW2328IDY Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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