Healthcare Provider Details

I. General information

NPI: 1992097901
Provider Name (Legal Business Name): ELYSE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11838 BERNARDO PLAZA CT SUITE 110
SAN DIEGO CA
92128-2413
US

IV. Provider business mailing address

2160 MONTCLAIR ST
SAN DIEGO CA
92104-5341
US

V. Phone/Fax

Practice location:
  • Phone: 858-673-5437
  • Fax:
Mailing address:
  • Phone: 951-212-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number1347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: