Provider Demographics
NPI:1053567701
Name:CAMPBELL, SAMUEL A
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
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 1:649 E ALBERTONI ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1538
Mailing Address - Country:US
Mailing Address - Phone:310-436-9300
Mailing Address - Fax:
Practice Address - Street 1:649 E ALBERTONI ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1538
Practice Address - Country:US
Practice Address - Phone:310-436-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist