Provider Demographics
NPI:1285125211
Name:CAMPOLI, BRIAN MATTHEW (PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MATTHEW
Last Name:CAMPOLI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BOYACK RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-7416
Mailing Address - Country:US
Mailing Address - Phone:518-209-3649
Mailing Address - Fax:
Practice Address - Street 1:32 MARKET PLACE
Practice Address - Street 2:
Practice Address - City:BIG SKY
Practice Address - State:MT
Practice Address - Zip Code:59716
Practice Address - Country:US
Practice Address - Phone:406-995-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13264225100000X
COPTL.0015447225100000X
OR62403225100000X
MTPTP-PT-LIC-14931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist