Provider Demographics
NPI:1720759939
Name:CAMPBELL, SUSANNA G
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:G
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 1:4200 MUNSON ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2981
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:330-915-2958
Practice Address - Street 1:4200 MUNSON ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2981
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:330-915-2958
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional