Provider Demographics
NPI:1962959114
Name:CAMPBELL, MARY E (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 W LIEBAU RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3397
Mailing Address - Country:US
Mailing Address - Phone:262-243-4161
Mailing Address - Fax:
Practice Address - Street 1:1249 W LIEBAU RD STE 100
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3397
Practice Address - Country:US
Practice Address - Phone:262-243-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic