Provider Demographics
NPI:1194261065
Name:CAMPBELL, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-3934
Mailing Address - Country:US
Mailing Address - Phone:731-855-7984
Mailing Address - Fax:731-855-7779
Practice Address - Street 1:2017 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-3934
Practice Address - Country:US
Practice Address - Phone:731-855-7984
Practice Address - Fax:731-855-7779
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6132225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant