Provider Demographics
NPI:1588968010
Name:CAMPBELL, KATHARINE MARIE (PHD, LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHARINE
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23774
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33307-3774
Mailing Address - Country:US
Mailing Address - Phone:954-507-0137
Mailing Address - Fax:954-909-4480
Practice Address - Street 1:1881 NE 26TH ST
Practice Address - Street 2:SUITE 70
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1416
Practice Address - Country:US
Practice Address - Phone:954-507-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFO474YMedicare PIN