MEDICARE: LAQUANITA SHANEL CAMPBELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
3	320700000X	Physical Disabilities Residential Treatment Facility
4	323P00000X	Psychiatric Residential Treatment Facility
5	3245S0500X	Children's Substance Abuse Rehabilitation Facility
6	164X00000X	Licensed Vocational Nurse	210151	TX

General Provider Information

NPI Number	:	1093991069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAQUANITA SHANEL CAMPBELL

Provider Business Mailing Address
First Line	:	6814 STABLETON LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77049-2054
Country	:	US
Telephone Number	:	713-548-7438
Fax Number	:

Provider Business Practice Location Address
First Line	:	6814 STABLETON LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77049-2054
Country	:	US
Telephone Number	:	713-548-7438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2008
Last Update Date	:	07/26/2012

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