Provider Demographics
NPI:1124729306
Name:CAMPBELL, KEEGAN DANIEL (LICSW)
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:DANIEL
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 HIGH ST STE 509
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5454
Mailing Address - Country:US
Mailing Address - Phone:304-996-3639
Mailing Address - Fax:
Practice Address - Street 1:235 HIGH ST STE 509
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5454
Practice Address - Country:US
Practice Address - Phone:304-996-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009453101041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVDP00945310OtherWEST VIRGINIA BOARD OF SOCIAL WORK