Provider Demographics
NPI:1962239905
Name:CAMPBELL, TARA LOR (LLPC, SCL)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LOR
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LLPC, SCL
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LOR
Other - Last Name:QUISENBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 BARRON RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8428
Mailing Address - Country:US
Mailing Address - Phone:719-650-7344
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 871942
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-7642
Practice Address - Country:US
Practice Address - Phone:719-650-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023478101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor