Provider Demographics
NPI:1053092031
Name:CAMPBELL, TROY MATTHEW
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:MATTHEW
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11055 E WAGON TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636-9680
Mailing Address - Country:US
Mailing Address - Phone:307-258-7917
Mailing Address - Fax:
Practice Address - Street 1:11055 E WAGON TRAIL RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WY
Practice Address - Zip Code:82636-9680
Practice Address - Country:US
Practice Address - Phone:307-258-7917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services