Healthcare Provider Details

I. General information

NPI: 1609088491
Provider Name (Legal Business Name): TED CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MOORE ST
FAIRBANKS AK
99701-5761
US

IV. Provider business mailing address

1717 W COWLES ST
FAIRBANKS AK
99701-5926
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-8251
  • Fax:
Mailing address:
  • Phone: 907-452-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: