Provider Demographics
NPI:1992097901
Name:CAMPBELL, ELYSE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
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 1:2160 MONTCLAIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5341
Mailing Address - Country:US
Mailing Address - Phone:951-212-1667
Mailing Address - Fax:
Practice Address - Street 1:11838 BERNARDO PLAZA CT
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2413
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13472355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant