Provider Demographics
NPI:1104417104
Name:CAMPBELL, KERRY ANN KIMBERLY
Entity type:Individual
Prefix:
First Name:KERRY ANN
Middle Name:KIMBERLY
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KERRY ANN
Other - Middle Name:KIMBERLY
Other - Last Name:TALBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8210 FLORIDA DR APT 134
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4567
Mailing Address - Country:US
Mailing Address - Phone:954-861-8002
Mailing Address - Fax:
Practice Address - Street 1:5400 S UNIVERSITY DR STE 504
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-5313
Practice Address - Country:US
Practice Address - Phone:888-398-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUNKNOWN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty