Basic Information
| Provider Information | |||||||||
| NPI: | 1578641734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHDLCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 S ORANGE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328062944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076507000 | ||||||||
| FaxNumber: | 4076507124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW4769 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | SW4769 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2080P0006X | SW4769 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
No ID Information.