Basic Information
| Provider Information | |||||||||
| NPI: | 1326236910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
| FaxNumber: | 3367163202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2572 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6107528 | 05 | NC | MEDICAID | 811451 | 01 | NC | PARTNERS | OTHER | 3810010805 | 05 | WV | MEDICAID | 9340091 | 01 | NC | AETNA | OTHER | 203479 | 01 | NC | MEDCOST | OTHER |