MEDICARE: MRS. SHADA MARIE CAMPBELL M.S.

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	235Z00000X	Speech-Language Pathologist	9226	MN

General Provider Information

NPI Number	:	1750831673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHADA MARIE CAMPBELL M.S.

Provider Business Mailing Address
First Line	:	1456 HOLTON ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-2324
Country	:	US
Telephone Number	:	949-466-2287
Fax Number	:

Provider Business Practice Location Address
First Line	:	1456 HOLTON ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-2324
Country	:	US
Telephone Number	:	949-466-2287
Fax Number	:

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

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/04/2016

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Directions to “ MRS. SHADA MARIE CAMPBELL M.S.” Practice Location

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