Provider Demographics
NPI:1174782536
Name:CAMPBELL, SHIRLEY JANE (MS,MED)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:JANE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS,MED
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:JANE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,MED
Mailing Address - Street 1:43 SHERMAN HILL RD
Mailing Address - Street 2:BLDG D-SUITE 203
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3651
Mailing Address - Country:US
Mailing Address - Phone:203-266-4142
Mailing Address - Fax:
Practice Address - Street 1:43 SHERMAN HILL RD
Practice Address - Street 2:BLDG D-SUITE 203
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3651
Practice Address - Country:US
Practice Address - Phone:203-266-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health