Healthcare Provider Details

I. General information

NPI: 1265932701
Provider Name (Legal Business Name): KELLY LYNN CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 MAIN ST STE G
EAST HARTFORD CT
06118-3239
US

IV. Provider business mailing address

1333 S MAYFLOWER AVE STE 220
MONROVIA CA
91016-4066
US

V. Phone/Fax

Practice location:
  • Phone: 888-754-0398
  • Fax:
Mailing address:
  • Phone: 818-241-6780
  • Fax: 800-819-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-50471
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: