Healthcare Provider Details

I. General information

NPI: 1093754509
Provider Name (Legal Business Name): CELESTE ANNE CAMPBELL PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 PARKLAKE DR NE STE 551
ATLANTA GA
30345-2951
US

IV. Provider business mailing address

3396 SHADY HOLLOW RUN
STONE MOUNTAIN GA
30087-4252
US

V. Phone/Fax

Practice location:
  • Phone: 703-867-6016
  • Fax: 470-231-1080
Mailing address:
  • Phone: 703-867-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810001978
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY003853
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810001978
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003853
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: