Provider Demographics
NPI:1588278550
Name:CAMPBELL, MOSELLE
Entity type:Individual
Prefix:
First Name:MOSELLE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HARTWELL AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-3160
Mailing Address - Country:US
Mailing Address - Phone:781-541-4464
Mailing Address - Fax:
Practice Address - Street 1:81 HARTWELL AVE STE 310
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-3160
Practice Address - Country:US
Practice Address - Phone:781-541-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003967103TC0700X
CT3967103TC2200X
MAPSY50000441103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical