Provider Demographics
NPI:1396088282
Name:CAMPBELL, MYRA IRENE (LPC)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:IRENE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO DRAWER 367
Mailing Address - Street 2:
Mailing Address - City:LAPWAI
Mailing Address - State:ID
Mailing Address - Zip Code:83540
Mailing Address - Country:US
Mailing Address - Phone:208-843-2271
Mailing Address - Fax:208-843-2102
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLAC-7239101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1000001OtherWA STATE LICENSE