Provider Demographics
NPI:1194950154
Name:CAMPBELL, MARY LAVINIA (LCSWR, CDE)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LAVINIA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LCSWR, CDE
Other - Prefix:MRS
Other - First Name:LIN
Other - Middle Name:X
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWR, CDE
Mailing Address - Street 1:80 E 11TH ST
Mailing Address - Street 2:438
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6811
Mailing Address - Country:US
Mailing Address - Phone:212-533-3884
Mailing Address - Fax:718-855-3004
Practice Address - Street 1:80 E 11TH ST
Practice Address - Street 2:438
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6811
Practice Address - Country:US
Practice Address - Phone:212-533-3884
Practice Address - Fax:718-855-3004
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-0376750103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst