Healthcare Provider Details

I. General information

NPI: 1356869226
Provider Name (Legal Business Name): MR. MARK THOMAS CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 N MARKS AVE STE 110
FRESNO CA
93711-0268
US

IV. Provider business mailing address

7120 N MARKS AVE STE 110
FRESNO CA
93711-0268
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-5437
  • Fax:
Mailing address:
  • Phone: 559-476-2166
  • Fax: 884-563-6035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: