Provider Demographics
NPI:1386142529
Name:HARRIS CAMPBELL, DANIELLA T'IARA (MCJ, CADC)
Entity type:Individual
Prefix:
First Name:DANIELLA
Middle Name:T'IARA
Last Name:HARRIS CAMPBELL
Suffix:
Gender:F
Credentials:MCJ, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52802-3644
Mailing Address - Country:US
Mailing Address - Phone:563-322-2667
Mailing Address - Fax:563-322-3671
Practice Address - Street 1:1523 S FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52802-3644
Practice Address - Country:US
Practice Address - Phone:563-322-2667
Practice Address - Fax:563-322-3671
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15085101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)