Healthcare Provider Details

I. General information

NPI: 1376821272
Provider Name (Legal Business Name): LAURA L CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA BERND

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

IV. Provider business mailing address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

V. Phone/Fax

Practice location:
  • Phone: 812-339-1691
  • Fax: 812-337-2438
Mailing address:
  • Phone: 812-339-1691
  • Fax: 812-337-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: