Provider Demographics
NPI:1306962253
Name:CAMPBELL, QULANTA MONETE (OT)
Entity type:Individual
Prefix:MISS
First Name:QULANTA
Middle Name:MONETE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 COUNTY ROAD 17
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422
Mailing Address - Country:US
Mailing Address - Phone:601-764-2384
Mailing Address - Fax:
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4119
Practice Address - Fax:601-426-4768
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2073225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist