MEDICARE: GENESIS 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	106H00000X	Marriage & Family Therapist	152452	CA

General Provider Information

NPI Number	:	1255045050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENESIS CAMPBELL

Provider Business Mailing Address
First Line	:	5880 FAIR ISLE DR APT 12
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-8452
Country	:	US
Telephone Number	:	904-803-2725
Fax Number	:

Provider Business Practice Location Address
First Line	:	5880 FAIR ISLE DR APT 12
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-8452
Country	:	US
Telephone Number	:	904-803-2725
Fax Number	:

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

Provider Enumeration Date	:	01/06/2023
Last Update Date	:	01/13/2025

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Directions to “ GENESIS CAMPBELL ” Practice Location

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