Provider Demographics
NPI:1306943030
Name:CAMPBELL, KRISTEN L (PHD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 DOGWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-0343
Mailing Address - Country:US
Mailing Address - Phone:662-549-7378
Mailing Address - Fax:
Practice Address - Street 1:105 5TH ST N
Practice Address - Street 2:SUITE 304
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-4568
Practice Address - Country:US
Practice Address - Phone:662-549-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC730103TC0700X
MS47 814103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q341210281Medicare ID - Type Unspecified