Provider Demographics
NPI:1063728558
Name:CAMPBELL, MICHELLE (CCC-SLP, BCBA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:BLUFF DALE
Mailing Address - State:TX
Mailing Address - Zip Code:76433-0277
Mailing Address - Country:US
Mailing Address - Phone:817-408-8395
Mailing Address - Fax:
Practice Address - Street 1:255 ANGLERS RIDGE
Practice Address - Street 2:
Practice Address - City:BLUFF DALE
Practice Address - State:TX
Practice Address - Zip Code:76433
Practice Address - Country:US
Practice Address - Phone:817-408-8395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-10-7216103K00000X
TX17279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80S906OtherBCBS
TX214308301Medicaid