Provider Demographics
NPI:1275379463
Name:CAMPBELL, MOLEIK JAHAUD (MOT)
Entity type:Individual
Prefix:
First Name:MOLEIK
Middle Name:JAHAUD
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6759 TRAIL SIDE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5195
Mailing Address - Country:US
Mailing Address - Phone:334-868-3878
Mailing Address - Fax:
Practice Address - Street 1:1995 N PARK PL SE STE 410
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2072
Practice Address - Country:US
Practice Address - Phone:770-850-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009219225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist