Provider Demographics
NPI:1104246867
Name:CAMPBELL, EDNA LEA (LPC-S)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:LEA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:LEA
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2224 APACHE ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-3005
Mailing Address - Country:US
Mailing Address - Phone:708-882-7484
Mailing Address - Fax:
Practice Address - Street 1:2224 APACHE ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-3005
Practice Address - Country:US
Practice Address - Phone:708-882-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10228101YM0800X
ARP1609141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health