Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 106S00000X | Behavior Technician | BH001975 | PA |
NPI | 1003399601 |
---|---|
Provider Name | Juanita M Campbell |
First Address | Philadelphia, PA 19153-1734 |
Second Address | Philadelphia, PA 19142-2604 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2018 |
Last Update Date | 10/09/2018 |