MEDICARE: MS. DOMINIQUE 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	103K00000X	Behavior Analyst	3598310	AZ

General Provider Information

NPI Number	:	1568885796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOMINIQUE CAMPBELL

Provider Business Mailing Address
First Line	:	1417 E APOLLO RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4446
Country	:	US
Telephone Number	:	480-321-5631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 E APOLLO RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4446
Country	:	US
Telephone Number	:	480-321-5631
Fax Number	:

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

Provider Enumeration Date	:	01/23/2014
Last Update Date	:	01/23/2014

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