Provider Demographics
NPI:1588904486
Name:CAMPBELL, AUDREY (MSW)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W PIONEER PKWY STE 6
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1883
Mailing Address - Country:US
Mailing Address - Phone:309-253-2471
Mailing Address - Fax:
Practice Address - Street 1:2000 W PIONEER PKWY STE 6
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1883
Practice Address - Country:US
Practice Address - Phone:309-253-2471
Practice Address - Fax:309-692-2052
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490155861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical