Provider Demographics
NPI:1336985308
Name:CAMPBELL, KEVIN PATRICK (CAMTC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CAMTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3781
Mailing Address - Country:US
Mailing Address - Phone:302-339-2584
Mailing Address - Fax:
Practice Address - Street 1:3637 GRAND AVE STE G
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2029
Practice Address - Country:US
Practice Address - Phone:302-339-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist