Provider Demographics
NPI:1225536295
Name:CAMPBELL, KENNEY
Entity type:Individual
Prefix:
First Name:KENNEY
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 1:6752 THADDEUS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6641
Mailing Address - Country:US
Mailing Address - Phone:682-667-2721
Mailing Address - Fax:
Practice Address - Street 1:3401 AMADOR DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-2227
Practice Address - Country:US
Practice Address - Phone:682-667-2721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist