Provider Demographics
NPI:1487710588
Name:CAMPBELL, LETHA (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LETHA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:LETHA
Other - Middle Name:
Other - Last Name:KOENIGHAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:5016 GRIST MILL DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5401
Mailing Address - Country:US
Mailing Address - Phone:770-783-9498
Mailing Address - Fax:877-977-9552
Practice Address - Street 1:5016 GRIST MILL DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5401
Practice Address - Country:US
Practice Address - Phone:770-783-9498
Practice Address - Fax:877-977-9552
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006046235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA571152749OtherBCBS
GA571152749OtherTRICARE
GA786634130AOtherPEACHSTATE
GA571152749OtherCOVENTRY
GA571152749OtherUNITED HEALTHCARE
GA100842OtherTRADING PARTNER
GA786634130AMedicaid
GA867779344AOtherPAYEE ID
GA786634130FMedicaid