Healthcare Provider Details

I. General information

NPI: 1679121891
Provider Name (Legal Business Name): TELISHA ROSE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 DUG GAP RD
DALTON GA
30720-5007
US

IV. Provider business mailing address

628 STAPP DR
RINGGOLD GA
30736-3015
US

V. Phone/Fax

Practice location:
  • Phone: 706-279-0405
  • Fax:
Mailing address:
  • Phone: 423-432-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: